Healthcare Provider Details

I. General information

NPI: 1891978870
Provider Name (Legal Business Name): GARRIT JACOBSON CCM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15501 SAN FERNANDO MISSION BLVD SUITE 302
MISSION HILLS CA
91345-1359
US

IV. Provider business mailing address

4328 KIMBERWICK LN
MOORPARK CA
93021-2309
US

V. Phone/Fax

Practice location:
  • Phone: 818-781-5511
  • Fax:
Mailing address:
  • Phone: 801-310-4296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7684422-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number36882
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW66054
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: