Provider Demographics
NPI:1821230681
Name:JACOBSON, STEPHEN MARK (PHD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CARSON ST
Mailing Address - Street 2:BOX 498
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:310-222-1643
Mailing Address - Fax:310-328-7217
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 498
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-1643
Practice Address - Fax:310-328-7217
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13213103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical