Provider Demographics
NPI:1821360199
Name:JACOBSEN, TIFFANY M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:M
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16535 W BLUEMOUND RD
Mailing Address - Street 2:STE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5906
Mailing Address - Country:US
Mailing Address - Phone:414-800-7645
Mailing Address - Fax:414-800-7647
Practice Address - Street 1:2448 S 102ND ST STE 270
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2147
Practice Address - Country:US
Practice Address - Phone:414-800-7645
Practice Address - Fax:414-800-7647
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3720-57103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist