MEDICARE: THERESE JACOBS-STEWART MA, LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	LP0906	MN

General Provider Information

NPI Number	:	1013122837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESE JACOBS-STEWART MA, LP

Provider Business Mailing Address
First Line	:	2046 SAINT CLAIR AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1650
Country	:	US
Telephone Number	:	651-225-1443
Fax Number	:

Provider Business Practice Location Address
First Line	:	2046 SAINT CLAIR AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1650
Country	:	US
Telephone Number	:	651-225-1443
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	11/30/2011

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