Basic Information
| Provider Information | |||||||||
| NPI: | 1821230681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 W CARSON ST | ||||||||
| Address2: | BOX 498 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905022004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102221643 | ||||||||
| FaxNumber: | 3103287217 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 W CARSON ST | ||||||||
| Address2: | BOX 498 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905022004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102221643 | ||||||||
| FaxNumber: | 3103287217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2009 | ||||||||
| LastUpdateDate: | 08/20/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY13213 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.