MEDICARE: BRUCE K JACOBSON PH D P C

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	261QM0850X	Adult Mental Health Clinic/Center	1162592501	UT

General Provider Information

NPI Number	:	1417913575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUCE K JACOBSON PH D P C

Provider Business Mailing Address
First Line	:	4190 HIGHLAND DR
Second Line	:	SUITE 211
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2600
Country	:	US
Telephone Number	:	801-272-0614
Fax Number	:	801-272-0678

Provider Business Practice Location Address
First Line	:	4190 HIGHLAND DR
Second Line	:	SUITE 211
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2600
Country	:	US
Telephone Number	:	801-272-0614
Fax Number	:	801-272-0678

Authorized Official
Title or Position	:	PRESIDENT AND PSYCHOLOGIST
Name	:	BRUCE K JACOBSON
Credential	:	PH D P C
Telephone Number	:	801-272-0614

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	03/16/2018

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