Provider Demographics
NPI:1790257822
Name:JACOBSON, SAUL (MS)
Entity Type:Individual
Prefix:
First Name:SAUL
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MS
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 52524
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92517-3524
Mailing Address - Country:US
Mailing Address - Phone:951-000-0000
Mailing Address - Fax:
Practice Address - Street 1:6746 VALJEAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-5851
Practice Address - Country:US
Practice Address - Phone:951-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1235650516106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician