Provider Demographics
NPI:1700017779
Name:JACOBO, MELISSA (LICSW, MAT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JACOBO
Suffix:
Gender:F
Credentials:LICSW, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 HIGH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-3026
Mailing Address - Country:US
Mailing Address - Phone:617-724-8234
Mailing Address - Fax:617-726-3514
Practice Address - Street 1:73 HIGH ST FL 3
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-3026
Practice Address - Country:US
Practice Address - Phone:617-724-8234
Practice Address - Fax:617-726-3514
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1149181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical