Provider Demographics
NPI:1356545107
Name:JACOBSEN, LAURA L (LCSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:JACOBSEN
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 1:19400 NW EVERGREEN PKWY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7031
Mailing Address - Country:US
Mailing Address - Phone:503-690-5027
Mailing Address - Fax:503-617-2333
Practice Address - Street 1:19400 NW EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7031
Practice Address - Country:US
Practice Address - Phone:503-690-5027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005234A1041C0700X
ORL42381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN165490Medicare ID - Type Unspecified