Provider Demographics
NPI:1841396447
Name:JACOBS, SUSAN LEE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEE
Last Name:JACOBS
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:PO BOX 1103
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92556-1103
Mailing Address - Country:US
Mailing Address - Phone:951-924-1868
Mailing Address - Fax:
Practice Address - Street 1:1330 W RAMSEY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4448
Practice Address - Country:US
Practice Address - Phone:951-849-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 182691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical