Provider Demographics
NPI:1053479352
Name:JACOBSON, TODD A (LCSW)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58646 MCNULTY WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-6210
Mailing Address - Country:US
Mailing Address - Phone:503-397-5211
Mailing Address - Fax:503-397-5373
Practice Address - Street 1:58646 MCNULTY WAY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6210
Practice Address - Country:US
Practice Address - Phone:503-397-5211
Practice Address - Fax:503-397-5373
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL23201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR139670Medicaid
OR100212Medicare PIN