Provider Demographics
NPI:1407493034
Name:JACOBSON, IAN
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 3RD AVE N #103
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020
Mailing Address - Country:US
Mailing Address - Phone:206-880-1822
Mailing Address - Fax:
Practice Address - Street 1:131 3RD AVE N STE 103
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3208
Practice Address - Country:US
Practice Address - Phone:425-418-9213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health