Provider Demographics
NPI:1689694135
Name:JACOBS, DANIELLE B (LCSW)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:B
Last Name:JACOBS
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 1:711 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5052
Mailing Address - Country:US
Mailing Address - Phone:715-284-5361
Mailing Address - Fax:
Practice Address - Street 1:711 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5052
Practice Address - Country:US
Practice Address - Phone:715-284-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7131-123106H00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40980700Medicaid
WI40980700Medicaid