Provider Demographics
NPI:1417915505
Name:JACOBSEN, DEBRA ANN (MS)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:ANN
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:DEBRA
Other - Middle Name:A
Other - Last Name:JOHANNTOBERNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3191 S VALLEY STREET
Mailing Address - Street 2:STE 210
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-4218
Mailing Address - Country:US
Mailing Address - Phone:801-565-2040
Mailing Address - Fax:801-583-5400
Practice Address - Street 1:3191 S VALLEY STREET
Practice Address - Street 2:STE 210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-4218
Practice Address - Country:US
Practice Address - Phone:801-565-2040
Practice Address - Fax:801-583-5400
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1997843902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist