Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 1595057 | WI |
Y | 103T00000X | Psychologist | 1595057 | WI |
NPI | 1003917907 |
---|---|
Provider Name | Monica I Jacobson |
First Address | Kewaunee, WI 54216 |
Second Address | Kewaunee, WI 54216 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
39089700 | (05) | WI |