Provider Demographics
NPI:1659746618
Name:JACOBSEN, JASEN F
Entity Type:Individual
Prefix:
First Name:JASEN
Middle Name:F
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:
Practice Address - Street 1:2508 SE 20TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4008
Practice Address - Country:US
Practice Address - Phone:479-273-9088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
AR12323-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)