Provider Demographics
NPI:1962520874
Name:JACOBSON, ABBY (MA, LCDP)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MA, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 HARMONY HILL RD
Mailing Address - Street 2:
Mailing Address - City:CHEPACHET
Mailing Address - State:RI
Mailing Address - Zip Code:02814-1429
Mailing Address - Country:US
Mailing Address - Phone:401-949-0690
Mailing Address - Fax:401-949-4412
Practice Address - Street 1:63 HARMONY HILL RD
Practice Address - Street 2:
Practice Address - City:CHEPACHET
Practice Address - State:RI
Practice Address - Zip Code:02814-1429
Practice Address - Country:US
Practice Address - Phone:401-949-0690
Practice Address - Fax:401-949-4412
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000121103TA0400X, 101YA0400X
RICDP00512101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2033065OtherCIGNA