Provider Demographics
NPI:1659620482
Name:JACOBSON, ADRIENNE L (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:L
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ANNA LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5303
Mailing Address - Country:US
Mailing Address - Phone:217-971-8987
Mailing Address - Fax:
Practice Address - Street 1:2035 W ILES AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4192
Practice Address - Country:US
Practice Address - Phone:217-726-1946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-08-4191103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst