Provider Demographics
NPI:1891978870
Name:JACOBSON, GARRIT (CCM)
Entity Type:Individual
Prefix:
First Name:GARRIT
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4328 KIMBERWICK LN
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2309
Mailing Address - Country:US
Mailing Address - Phone:801-310-4296
Mailing Address - Fax:
Practice Address - Street 1:15501 SAN FERNANDO MISSION BLVD
Practice Address - Street 2:SUITE 302
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1359
Practice Address - Country:US
Practice Address - Phone:818-781-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT7684422-35011041C0700X
CA368821041C0700X
CALCSW660541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator