Provider Demographics
NPI:1053527390
Name:JACOBSEN, KAREN DEANE (LICENSED COUNSELOR)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:DEANE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:LICENSED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-1340
Mailing Address - Country:US
Mailing Address - Phone:509-422-5700
Mailing Address - Fax:509-422-7680
Practice Address - Street 1:1003 KOALA AVE
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9247
Practice Address - Country:US
Practice Address - Phone:509-422-5700
Practice Address - Fax:509-422-7680
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007846101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH00007846OtherSTATE LICENSE
WA1053527390OtherSBIRT
WA2038885Medicaid