Healthcare Provider Details

I. General information

NPI: 1538466792
Provider Name (Legal Business Name): JENNIFER M JACOBSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAKE VIEW DR
WAUSAU WI
54403-6785
US

IV. Provider business mailing address

1100 LAKE VIEW DR
WAUSAU WI
54403-6785
US

V. Phone/Fax

Practice location:
  • Phone: 715-848-4600
  • Fax: 715-845-6050
Mailing address:
  • Phone: 715-848-4600
  • Fax: 715-845-6050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8197123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: