MEDICARE: JACK JACOBSEN MSW, LCSW

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	1041C0700X	Clinical Social Worker	2007031620	MO

General Provider Information

NPI Number	:	1679751291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK JACOBSEN MSW, LCSW

Provider Business Mailing Address
First Line	:	3211 ALFRED AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63116-1809
Country	:	US
Telephone Number	:	314-569-9731
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 S GORE AVE
Second Line	:
City	:	WEBSTER GROVES
State	:	MO
Zip	:	63119-2910
Country	:	US
Telephone Number	:	314-736-5446
Fax Number	:

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

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	01/19/2021

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