Provider Demographics
NPI:1740413855
Name:JACOBSON, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
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 1:165 N VILLAGE AVE
Mailing Address - Street 2:SUITE #201
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3761
Mailing Address - Country:US
Mailing Address - Phone:516-984-2477
Mailing Address - Fax:
Practice Address - Street 1:165 N VILLAGE AVE
Practice Address - Street 2:SUITE #201
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3761
Practice Address - Country:US
Practice Address - Phone:516-984-2477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068465104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker