Provider Demographics
NPI:1730316167
Name:JACOBSON, SUSAN
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20548 BRIAN CRES
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1142
Mailing Address - Country:US
Mailing Address - Phone:516-661-6666
Mailing Address - Fax:
Practice Address - Street 1:310 E SHORE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2410
Practice Address - Country:US
Practice Address - Phone:516-661-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010031103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent