Provider Demographics
NPI:1437385796
Name:JACOBS, SUSAN G (LADC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 724
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-0724
Mailing Address - Country:US
Mailing Address - Phone:802-334-6744
Mailing Address - Fax:802-334-7340
Practice Address - Street 1:154 DUCHESS STREET
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855
Practice Address - Country:US
Practice Address - Phone:802-334-7451
Practice Address - Fax:802-334-7340
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000468101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)