Provider Demographics
NPI:1750920443
Name:JACOBSON, GRACE K (PSYD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:K
Last Name:JACOBSON
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 1:1 12TH ST STE 208
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-4146
Mailing Address - Country:US
Mailing Address - Phone:503-470-1520
Mailing Address - Fax:503-470-1191
Practice Address - Street 1:1 12TH ST STE 208
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4146
Practice Address - Country:US
Practice Address - Phone:503-470-1520
Practice Address - Fax:503-470-1191
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6492103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical