Provider Demographics
NPI:1992932479
Name:JACOBSEN, JAKE HEATH (ATR, LCSW)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:HEATH
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:ATR, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6124 SE MILWAUKIE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5347
Mailing Address - Country:US
Mailing Address - Phone:347-449-4565
Mailing Address - Fax:
Practice Address - Street 1:6124 SE MILWAUKIE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5347
Practice Address - Country:US
Practice Address - Phone:347-449-4565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-11
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069903-11041C0700X
NY0699031041C0700X
ORL60161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical