Provider Demographics
NPI:1619352184
Name:JACOBS, ALISON
Entity Type:Individual
Prefix:
First Name:ALISON
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N WESTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-5715
Mailing Address - Country:US
Mailing Address - Phone:920-750-7000
Mailing Address - Fax:
Practice Address - Street 1:12630 W NORTH AVE BLDG E
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4626
Practice Address - Country:US
Practice Address - Phone:262-785-1008
Practice Address - Fax:262-432-9059
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1931-226101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health