Provider Demographics
NPI:1912039298
Name:JACOBSON, MARTHA CANDACE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:CANDACE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 HOLLYWOOD BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6760
Mailing Address - Country:US
Mailing Address - Phone:954-987-8812
Mailing Address - Fax:954-987-2615
Practice Address - Street 1:3900 HOLLYWOOD BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6760
Practice Address - Country:US
Practice Address - Phone:954-987-8812
Practice Address - Fax:954-987-2615
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004227103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73505OtherBL CROSS BL SHIELD NUMBER
FL73505Medicare ID - Type UnspecifiedPROVIDER NUMBER