Healthcare Provider Details

I. General information

NPI: 1659465607
Provider Name (Legal Business Name): JULIENNE RAQUEL JACOBSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MS# 82
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

3250 WILSHIRE BLVD STE 1101
LOS ANGELES CA
90010-1513
US

V. Phone/Fax

Practice location:
  • Phone: 323-669-2471
  • Fax: 323-667-2019
Mailing address:
  • Phone: 323-361-2336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA68305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: