MEDICARE: JOSHUA MICHAEL JACOBSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1023381670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSHUA MICHAEL JACOBSON

Provider Business Mailing Address
First Line	:	463B ERNEST BILES DR
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-2229
Country	:	US
Telephone Number	:	770-504-5645
Fax Number	:	770-504-5646

Provider Business Practice Location Address
First Line	:	463B ERNEST BILES DR
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-2229
Country	:	US
Telephone Number	:	770-504-5645
Fax Number	:	770-504-5646

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2012
Last Update Date	:	02/13/2012

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