Provider Demographics
NPI:1134783350
Name:JACOBSEN, DIANA CHRISTINE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:CHRISTINE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10698 RIDGEPOLE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80925-1410
Mailing Address - Country:US
Mailing Address - Phone:914-826-0343
Mailing Address - Fax:
Practice Address - Street 1:322 S ELLICOTT HWY
Practice Address - Street 2:
Practice Address - City:CALHAN
Practice Address - State:CO
Practice Address - Zip Code:80808
Practice Address - Country:US
Practice Address - Phone:719-683-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.00099214581041S0200X
COCSW.099270481041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool