MEDICARE: REBECCA JACOBSON THERAPY, LLC

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

General Provider Information

NPI Number	:	1811538416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REBECCA JACOBSON THERAPY, LLC

Provider Business Mailing Address
First Line	:	1827 N DAYTON ST UNIT E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-0999
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1827 N DAYTON ST UNIT E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-0999
Country	:	US
Telephone Number	:	847-421-9136
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	REBECCA JACOBSON
Credential	:	LCSW
Telephone Number	:	847-421-9136

Provider Enumeration Date	:	10/04/2019
Last Update Date	:	10/04/2019

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