Provider Demographics
NPI:1679751291
Name:JACOBSEN, JACK (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 ALFRED AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1809
Mailing Address - Country:US
Mailing Address - Phone:314-569-9731
Mailing Address - Fax:
Practice Address - Street 1:24 S GORE AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2910
Practice Address - Country:US
Practice Address - Phone:314-736-5446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070316201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical