Provider Demographics
NPI:1588435788
Name:JACOBSON, AMANDA JO (MS, LMFT-IT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MS, LMFT-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4694 BAYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-7616
Mailing Address - Country:US
Mailing Address - Phone:715-490-5965
Mailing Address - Fax:
Practice Address - Street 1:8A W DAVENPORT ST
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3467
Practice Address - Country:US
Practice Address - Phone:715-490-5965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1077-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist