Provider Demographics
NPI:1558040105
Name:JACOBSEN, AUSTIN
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 NICOLLET AVE APT 2404
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2930
Mailing Address - Country:US
Mailing Address - Phone:920-242-5615
Mailing Address - Fax:
Practice Address - Street 1:1370 MENDOTA HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120-1281
Practice Address - Country:US
Practice Address - Phone:651-313-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health