Provider Demographics
NPI:1184777963
Name:JACOBSON, ELISA (LCSW)
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
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 1:655 E JERSEY ST
Mailing Address - Street 2:YOUTH CASE MANAGEMENT
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07206-1259
Mailing Address - Country:US
Mailing Address - Phone:908-994-7380
Mailing Address - Fax:908-994-7322
Practice Address - Street 1:655 E JERSEY ST
Practice Address - Street 2:YOUTH CASE MANAGEMENT
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07206-1259
Practice Address - Country:US
Practice Address - Phone:908-994-7380
Practice Address - Fax:908-994-7322
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC04855600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023302Medicaid