Provider Demographics
NPI:1770216145
Name:JACOBSEN, STEPHEN (LMSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 HARTFORD TPKE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5017
Mailing Address - Country:US
Mailing Address - Phone:860-870-5997
Mailing Address - Fax:860-870-8170
Practice Address - Street 1:550 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5017
Practice Address - Country:US
Practice Address - Phone:860-870-5997
Practice Address - Fax:860-870-8170
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6479104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker