Provider Demographics
NPI:1780676577
Name:JACOBSON, AMY C (LCSW-R)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1561
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12402-1561
Mailing Address - Country:US
Mailing Address - Phone:845-943-0405
Mailing Address - Fax:845-255-0104
Practice Address - Street 1:113 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-1005
Practice Address - Country:US
Practice Address - Phone:845-255-3474
Practice Address - Fax:845-255-0104
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR050042-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR050042-1OtherLCSW-R LICENSE
NYR050042-1OtherLCSW-R LICENSE