1447352802 NPI number — MR. LARRY JAMES JACOBSEN, JR. MA, LMFT

Table of content: MR. LARRY JAMES JACOBSEN, JR. MA, LMFT (NPI 1447352802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447352802 NPI number — MR. LARRY JAMES JACOBSEN, JR. MA, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBSEN, JR.
Provider First Name:
LARRY
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACOBSEN
Provider Other First Name:
JIM
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, LMFT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1447352802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1775 E PALM CANYON DR STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM SPRINGS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92264-1623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9890 COUNTY FARM RD STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92503-3678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-509-2499
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC 42093 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com