Provider Demographics
NPI:1295774230
Name:JACOBSON, MYRNA (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:MYRNA
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 EAST PIONEER DRIVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-9235
Mailing Address - Country:US
Mailing Address - Phone:970-259-2723
Mailing Address - Fax:
Practice Address - Street 1:123 WEEMINUCHE
Practice Address - Street 2:
Practice Address - City:IGNACIO
Practice Address - State:CO
Practice Address - Zip Code:81137
Practice Address - Country:US
Practice Address - Phone:970-563-4581
Practice Address - Fax:970-563-0206
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2616103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07043391Medicaid
COP47273Medicare UPIN
CO07043391Medicaid