MEDICARE: KIRSTEN ANNE JACOBSON LCSW

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	104100000X	Social Worker	7746360-3502	UT
2	1041C0700X	Clinical Social Worker	746360-3501	UT
3	1041C0700X	Clinical Social Worker	7746360-3501	UT

General Provider Information

NPI Number	:	1730456104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTEN ANNE JACOBSON LCSW

Provider Business Mailing Address
First Line	:	1133 N MAIN ST STE 100
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-4868
Country	:	US
Telephone Number	:	801-833-7536
Fax Number	:

Provider Business Practice Location Address
First Line	:	1133 N MAIN ST STE 100
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-4868
Country	:	US
Telephone Number	:	801-833-7536
Fax Number	:

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

Provider Enumeration Date	:	11/29/2011
Last Update Date	:	10/29/2024

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