Provider Demographics
NPI:1407060254
Name:JACOBSON, STUART IRV (LICENSED CLINICAL SO)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:IRV
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4528 SOUTH SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145
Mailing Address - Country:US
Mailing Address - Phone:918-745-2463
Mailing Address - Fax:
Practice Address - Street 1:4528 SOUTH SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145
Practice Address - Country:US
Practice Address - Phone:918-745-2463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLCSW00081041C0700X
OKLMFT334106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist