Provider Demographics
NPI:1053794818
Name:JACOBSON, LILLY GLANCY (PHD)
Entity type:Individual
Prefix:DR
First Name:LILLY
Middle Name:GLANCY
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MARTELL DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3447
Mailing Address - Country:US
Mailing Address - Phone:248-835-4749
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-832-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016104103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical