MEDICARE: MS. CHARLENE R JACOBS

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	101YM0800X	Mental Health Counselor	3997	MA

General Provider Information

NPI Number	:	1467448910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHARLENE R JACOBS

Provider Business Mailing Address
First Line	:	21 REGAL ST
Second Line	:
City	:	HOLLISTON
State	:	MA
Zip	:	01746-1808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 REGAL ST
Second Line	:
City	:	HOLLISTON
State	:	MA
Zip	:	01746-1808
Country	:	US
Telephone Number	:	508-429-5242
Fax Number	:

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

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	07/08/2007

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