Provider Demographics
NPI:1760251755
Name:JACOBSON, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
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 1:3410 WENTWORTH WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-1882
Mailing Address - Country:US
Mailing Address - Phone:417-699-1729
Mailing Address - Fax:
Practice Address - Street 1:3410 WENTWORTH WAY
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-1882
Practice Address - Country:US
Practice Address - Phone:417-699-1729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89477101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional