Provider Demographics
NPI:1679743009
Name:JACOBSON, BRUCE KENNETH (PHD, PC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:KENNETH
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PHD, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 HIGHLAND DR
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2600
Mailing Address - Country:US
Mailing Address - Phone:801-272-0614
Mailing Address - Fax:
Practice Address - Street 1:4190 HIGHLAND DR
Practice Address - Street 2:SUITE 211
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2600
Practice Address - Country:US
Practice Address - Phone:801-272-0614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT450510082103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist