Provider Demographics
NPI:1770652596
Name:JACOBSON, DIANA J (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:J
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 PIERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960
Mailing Address - Country:US
Mailing Address - Phone:845-353-8322
Mailing Address - Fax:845-353-8341
Practice Address - Street 1:50 PIERMONT AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960
Practice Address - Country:US
Practice Address - Phone:845-353-8322
Practice Address - Fax:845-353-8341
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR018103104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01758754Medicaid
NYR018103OtherLICENSE NYS
NYR018103OtherLICENSE NYS