Provider Demographics
NPI:1154051191
Name:JACOBSON, MAYA CLOTILDE
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:CLOTILDE
Last Name:JACOBSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-3330
Mailing Address - Country:US
Mailing Address - Phone:510-543-0078
Mailing Address - Fax:
Practice Address - Street 1:400 ESTUDILLO AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4962
Practice Address - Country:US
Practice Address - Phone:510-924-0548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 390200000X
CA141610106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program