Provider Demographics
NPI:1881419851
Name:JACOBSON, MARIANN SUE
Entity type:Individual
Prefix:
First Name:MARIANN
Middle Name:SUE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-3243
Mailing Address - Country:US
Mailing Address - Phone:360-660-5525
Mailing Address - Fax:
Practice Address - Street 1:325 S. 3RD STREET
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584
Practice Address - Country:US
Practice Address - Phone:360-426-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)