Provider Demographics
NPI:1811180524
Name:JACOBSON, JEAN M (PHD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:M
Other - Last Name:HALLORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 ARMORY DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5405
Mailing Address - Country:US
Mailing Address - Phone:315-797-6241
Mailing Address - Fax:315-738-7777
Practice Address - Street 1:1020 MARY ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-1930
Practice Address - Country:US
Practice Address - Phone:315-724-6907
Practice Address - Fax:315-733-0791
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016479103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01039156Medicaid
NY01039156Medicaid
NYRB8549Medicare UPIN