Provider Demographics
NPI:1912524976
Name:JACOBSON, MARY (SW,SAC-IT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:SW,SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3228
Mailing Address - Country:US
Mailing Address - Phone:608-784-4357
Mailing Address - Fax:608-785-6122
Practice Address - Street 1:300 4TH ST N
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3228
Practice Address - Country:US
Practice Address - Phone:608-784-4357
Practice Address - Fax:608-785-6122
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19001-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)