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NPI Code Detail

MEDICARE: K.A. JACOBSON, PH.D., PLLC

MEDICARE: K.A. JACOBSON, PH.D., PLLC
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
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)LP0158MN

General Provider Information

NPI Number : 1154363414
Entity Type Code : Organization
Provider Name (Legal Business Name) : K.A. JACOBSON, PH.D., PLLC
Provider Business Mailing Address
First Line : 5101 OLSON MEMORIAL HWY
Second Line : SUITE 4003
City : GOLDEN VALLEY
State : MN
Zip : 55422-5149
Country : US
Telephone Number : 763-595-7294
Fax Number : 763-595-7293
Provider Business Practice Location Address
First Line : 5101 OLSON MEMORIAL HWY
Second Line : SUITE 4003
City : GOLDEN VALLEY
State : MN
Zip : 55422-5149
Country : US
Telephone Number : 763-595-7294
Fax Number : 763-595-7293
Authorized Official
Title or Position : CLINICAL PSYCHOLOGIST
Name : DR. KATHLEEN A. JACOBSON
Credential : PH.D.
Telephone Number : 763-595-7294
Provider Enumeration Date : 06/12/2006
Last Update Date : 08/22/2020

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