MEDICARE: MICHAELA AVERY JACOBSON

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
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1750078911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAELA AVERY JACOBSON

Provider Business Mailing Address
First Line	:	411 E 108TH TER
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64131-4017
Country	:	US
Telephone Number	:	913-626-6030
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 W MAIN ST STE 200
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64015-3743
Country	:	US
Telephone Number	:	913-626-6030
Fax Number	:

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

Provider Enumeration Date	:	04/19/2023
Last Update Date	:	04/19/2023

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