Provider Demographics
NPI:1578732863
Name:JACOBSEN, MARK PETER (PHD, LICSW)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:PETER
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 CONNECTICUT AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-1522
Mailing Address - Country:US
Mailing Address - Phone:703-521-1710
Mailing Address - Fax:
Practice Address - Street 1:2607 CONNECTICUT AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-1522
Practice Address - Country:US
Practice Address - Phone:703-521-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3034581041C0700X
MD066661041C0700X
VA09040047051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0001J475OtherBC/BS