Provider Demographics
NPI:1669012043
Name:JACOBSEN, JEANNA (LCSW)
Entity Type:Individual
Prefix:
First Name:JEANNA
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 KALSMAN DR UNIT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-4439
Mailing Address - Country:US
Mailing Address - Phone:801-842-2519
Mailing Address - Fax:
Practice Address - Street 1:3627 KALSMAN DR UNIT 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-4439
Practice Address - Country:US
Practice Address - Phone:801-842-2519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT360887-35011041C0700X
ORL42681041C0700X
CA847261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical