Provider Demographics
NPI:1285709253
Name:JACOBSON, CJ (PSYD)
Entity type:Individual
Prefix:DR
First Name:CJ
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MISS
Other - First Name:CORY
Other - Middle Name:LYNN
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:12353 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650
Mailing Address - Country:US
Mailing Address - Phone:562-484-3385
Mailing Address - Fax:562-484-0269
Practice Address - Street 1:12353 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650
Practice Address - Country:US
Practice Address - Phone:562-484-3385
Practice Address - Fax:562-484-0269
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1512013461Medicaid
CA1512013461Medicaid