Provider Demographics
NPI:1417913575
Name:BRUCE K JACOBSON PH D P C
Entity Type:Organization
Organization Name:BRUCE K JACOBSON PH D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PH D P C
Authorized Official - Phone:801-272-0614
Mailing Address - Street 1:4190 HIGHLAND DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2600
Mailing Address - Country:US
Mailing Address - Phone:801-272-0614
Mailing Address - Fax:801-272-0678
Practice Address - Street 1:4190 HIGHLAND DR
Practice Address - Street 2:SUITE 211
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2600
Practice Address - Country:US
Practice Address - Phone:801-272-0614
Practice Address - Fax:801-272-0678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1162592501261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health