Provider Demographics
NPI:1588310080
Name:JACOBOSKI, GARY MATTHEW (LPC-IT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MATTHEW
Last Name:JACOBOSKI
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 MENDOTA ST STE 120
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-1060
Mailing Address - Country:US
Mailing Address - Phone:608-280-2577
Mailing Address - Fax:
Practice Address - Street 1:1320 MENDOTA ST STE 120
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-1060
Practice Address - Country:US
Practice Address - Phone:608-800-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5188-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional