Provider Demographics
NPI:1912564469
Name:JAKOBSON, KIMBERLY BRETT
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BRETT
Last Name:JAKOBSON
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 1:1627 TRUMANSBURG RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9213
Mailing Address - Country:US
Mailing Address - Phone:504-296-1859
Mailing Address - Fax:
Practice Address - Street 1:1627 TRUMANSBURG RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-9213
Practice Address - Country:US
Practice Address - Phone:504-296-1859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106130104100000X
NY0953001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker