Basic Information
| Provider Information | |||||||||
| NPI: | 1144952797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSEN | ||||||||
| FirstName: | KRISTIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 WATERMARK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432157088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144383400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3631 EDISON RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466153715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002703756 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2022 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 33007368A | IN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.