Provider Demographics
NPI:1629476932
Name:JACOBSON, MAREN FRANCES (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:MAREN
Middle Name:FRANCES
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 E MOOR DALE LN
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6921
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:
Practice Address - Street 1:179 N 1200 E STE 101
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2148
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1-14-10027103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst