Provider Demographics
NPI:1568595544
Name:JACOBS, MARILYN SUSAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:SUSAN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10573 W. PICO BLVD.
Mailing Address - Street 2:#230
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-2333
Mailing Address - Country:US
Mailing Address - Phone:310-428-3667
Mailing Address - Fax:310-552-2151
Practice Address - Street 1:1626 WESTWOOD BLVD.
Practice Address - Street 2:#104
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5621
Practice Address - Country:US
Practice Address - Phone:310-428-3667
Practice Address - Fax:310-552-2151
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020945-01103T00000X
MI6301018613103T00000X
CAPSY11463103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200072700OtherOWCPUSDOL