=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053027805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDSEY MARIE JACOBSEN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2023
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6410 ENTERPRISE LANE SUITE 210
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-400-3672
-----------------------------------------------------
Fax | 608-422-4006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2342 TALC TRAIL APT. 202
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-400-3672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 132637-121
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 11730-123
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------