Provider Demographics
NPI:1972039873
Name:JACOBSON, EILEEN (CP00003047)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:CP00003047
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 4627
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-0627
Mailing Address - Country:US
Mailing Address - Phone:509-927-1543
Mailing Address - Fax:
Practice Address - Street 1:15407 E MISSION AVE STE 100
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8527
Practice Address - Country:US
Practice Address - Phone:509-927-1543
Practice Address - Fax:509-927-4761
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003047101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)