Provider Demographics
NPI:1194537969
Name:OBGYN PSYCHIATRY LLC
Entity type:Organization
Organization Name:OBGYN PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:NOELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP-C
Authorized Official - Phone:321-356-2881
Mailing Address - Street 1:200 MAITLAND AVE APT 142
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5539
Mailing Address - Country:US
Mailing Address - Phone:321-356-2881
Mailing Address - Fax:
Practice Address - Street 1:200 MAITLAND AVE APT 142
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5539
Practice Address - Country:US
Practice Address - Phone:321-356-2881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health