Provider Demographics
NPI:1184717894
Name:JACOBSON, ILYANA MARGARITA (LCSW)
Entity type:Individual
Prefix:
First Name:ILYANA
Middle Name:MARGARITA
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W SANTA ANA BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4552
Mailing Address - Country:US
Mailing Address - Phone:714-953-4455
Mailing Address - Fax:714-542-2793
Practice Address - Street 1:600 W SANTA ANA BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4552
Practice Address - Country:US
Practice Address - Phone:714-953-4455
Practice Address - Fax:915-772-5133
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24487104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S674OtherBLUE CROSS BLUE SHIEL
TX00210PMedicare ID - Type Unspecified