Provider Demographics
NPI:1871636043
Name:JACOBSEN, KELLI CLARK (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:CLARK
Last Name:JACOBSEN
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 1:450 S 900 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3064
Mailing Address - Country:US
Mailing Address - Phone:801-534-7916
Mailing Address - Fax:801-532-3608
Practice Address - Street 1:450 S 900 E STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-3064
Practice Address - Country:US
Practice Address - Phone:801-534-7916
Practice Address - Fax:801-532-3608
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6953774-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical