Basic Information
| Provider Information | |||||||||
| NPI: | 1295863801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.M.H.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSE | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1726 SE 3RD AVENUE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545224749 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 SE 18TH STREET | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545224749 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 768055400 | 05 | FL | MEDICAID |