Provider Demographics
NPI:1295966612
Name:RIORDAN JACOBSON, TRACEY ELIZABETH (LPC)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:ELIZABETH
Last Name:RIORDAN JACOBSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BUSINESS PARK DR
Mailing Address - Street 2:SUITE 203A
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2988
Mailing Address - Country:US
Mailing Address - Phone:203-871-9327
Mailing Address - Fax:
Practice Address - Street 1:6 BUSINESS PARK DR
Practice Address - Street 2:SUITE 203A
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2988
Practice Address - Country:US
Practice Address - Phone:203-871-9327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001790101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional