Provider Demographics
NPI:1437810413
Name:JACOBSON, DANA
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5114 CEDROS AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1404
Mailing Address - Country:US
Mailing Address - Phone:818-943-2348
Mailing Address - Fax:
Practice Address - Street 1:5114 CEDROS AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1404
Practice Address - Country:US
Practice Address - Phone:818-448-5788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP3566103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherDO NOT HAVE