Healthcare Provider Details

I. General information

NPI: 1962520874
Provider Name (Legal Business Name): ABBY JACOBSON MA, LCDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 HARMONY HILL RD
CHEPACHET RI
02814-1429
US

IV. Provider business mailing address

63 HARMONY HILL RD
CHEPACHET RI
02814-1429
US

V. Phone/Fax

Practice location:
  • Phone: 401-949-0690
  • Fax: 401-949-4412
Mailing address:
  • Phone: 401-949-0690
  • Fax: 401-949-4412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000121
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP00512
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number000121
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: