Provider Demographics
NPI:1588234637
Name:JACOBSON, JACY (LGSW)
Entity Type:Individual
Prefix:
First Name:JACY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2433 EMERSON AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-467-3519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN299891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical