Provider Demographics
NPI:1245435759
Name:JACOBSEN, MARY E (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 REDWING CIR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4273
Mailing Address - Country:US
Mailing Address - Phone:336-922-7152
Mailing Address - Fax:336-922-5239
Practice Address - Street 1:2594 REYNOLDA RD
Practice Address - Street 2:SUITE D
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4601
Practice Address - Country:US
Practice Address - Phone:336-671-6021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5110101YM0800X
MNMN3087103T00000X
VA0810003296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical