Provider Demographics
NPI:1013122837
Name:JACOBS-STEWART, THERESE (MA, LP)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:JACOBS-STEWART
Suffix:
Gender:F
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 SAINT CLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1650
Mailing Address - Country:US
Mailing Address - Phone:651-225-1443
Mailing Address - Fax:
Practice Address - Street 1:2046 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1650
Practice Address - Country:US
Practice Address - Phone:651-225-1443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0906103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling