Provider Demographics
NPI:1972517753
Name:JACOBSON, MARY E (LPC CCAC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LPC CCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-0423
Mailing Address - Country:US
Mailing Address - Phone:304-298-4082
Mailing Address - Fax:304-298-4082
Practice Address - Street 1:WATER STREET
Practice Address - Street 2:
Practice Address - City:FT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719-0423
Practice Address - Country:US
Practice Address - Phone:304-298-4082
Practice Address - Fax:304-298-4082
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWVLPC 1016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health