Basic Information
| Provider Information | |||||||||
| NPI: | 1710223235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOVSKY | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 4TH AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921016967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6198880203 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 480 ALTA RD | ||||||||
| Address2: | RICHARD J. DONOVAN CORRECTIONAL FACILITY | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921790001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196616500 | ||||||||
| FaxNumber: | 6196616357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2013 | ||||||||
| LastUpdateDate: | 01/02/2013 | ||||||||
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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 | 103T00000X | PSY18498 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.