Provider Demographics
NPI:1497070494
Name:JACOBSEN, THERESA JACOBSEN (BA, CAC III)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:JACOBSEN
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:BA, CAC III
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Mailing Address - Street 1:11721 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-1623
Mailing Address - Country:US
Mailing Address - Phone:303-451-9377
Mailing Address - Fax:303-452-4978
Practice Address - Street 1:25 E 16TH AVE
Practice Address - Street 2:BOX 4
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-5195
Practice Address - Country:US
Practice Address - Phone:720-327-2940
Practice Address - Fax:303-764-6270
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO1638101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1638OtherCOLORADO ADDICTIONS COUNSELOR