Provider Demographics
NPI:1982779831
Name:JACOBS, JON SCOTT (LMFT)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:SCOTT
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:M8898 250TH STREET
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54767
Mailing Address - Country:US
Mailing Address - Phone:715-778-4320
Mailing Address - Fax:
Practice Address - Street 1:408 RED CEDAR ST
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751
Practice Address - Country:US
Practice Address - Phone:715-235-4696
Practice Address - Fax:715-235-3941
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI397124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39174500Medicaid