Provider Demographics
NPI:1104085224
Name:JACOBSEN, CATHERINE ALICE
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:ALICE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:ALICE
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:74 FARNWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2921
Mailing Address - Country:US
Mailing Address - Phone:856-802-1968
Mailing Address - Fax:
Practice Address - Street 1:1200 S CHURCH ST
Practice Address - Street 2:SUITE 14
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2936
Practice Address - Country:US
Practice Address - Phone:609-304-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000963001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical