Provider Demographics
NPI:1013058320
Name:JACOBSEN, SUSAN CHARLOTTE (LMHC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CHARLOTTE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 INDIAN RUN TRL
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-1908
Mailing Address - Country:US
Mailing Address - Phone:401-742-1430
Mailing Address - Fax:
Practice Address - Street 1:64 INDIAN RUN TRL
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-1908
Practice Address - Country:US
Practice Address - Phone:401-742-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00294101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health