Provider Demographics
NPI:1891476107
Name:JACOBSON, REILLY (TLLP)
Entity Type:Individual
Prefix:
First Name:REILLY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 WESTOWN DR NW APT 303
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-3719
Mailing Address - Country:US
Mailing Address - Phone:515-468-1496
Mailing Address - Fax:
Practice Address - Street 1:640 3 MILE RD NW STE G
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8209
Practice Address - Country:US
Practice Address - Phone:616-369-8433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009732103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist