Provider Demographics
NPI:1124127766
Name:JACOBSON, LARRY KAY (LPC NCC)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:KAY
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 EAST 3050 NORTH
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-1936
Mailing Address - Country:US
Mailing Address - Phone:801-782-8129
Mailing Address - Fax:
Practice Address - Street 1:3500 HARRISON BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2058
Practice Address - Country:US
Practice Address - Phone:801-725-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1221526004101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor