Provider Demographics
NPI:1649469412
Name:JACOBSON, MADELEINE KAY (LICSW)
Entity type:Individual
Prefix:MRS
First Name:MADELEINE
Middle Name:KAY
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:MADELEINE
Other - Middle Name:KAY
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:30 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON HIGHLANDS
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1527
Mailing Address - Country:US
Mailing Address - Phone:617-332-8831
Mailing Address - Fax:
Practice Address - Street 1:30 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:NEWTON HIGHLANDS
Practice Address - State:MA
Practice Address - Zip Code:02461-1527
Practice Address - Country:US
Practice Address - Phone:617-332-8831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1030563101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJAPO2473OtherBLUE CROSS/BS INDEMNITY