Provider Demographics
NPI:1447320767
Name:JACOBSON, GLENN R
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 COURTYARD OFFICES
Mailing Address - Street 2:1372 N. SUSQUEHANNA TRAIL
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-9374
Mailing Address - Country:US
Mailing Address - Phone:570-743-2323
Mailing Address - Fax:570-743-2343
Practice Address - Street 1:7 COURTYARD OFFICES
Practice Address - Street 2:1372 N. SUSQUEHANNA TRAIL
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-9374
Practice Address - Country:US
Practice Address - Phone:570-743-2323
Practice Address - Fax:570-743-2343
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007127L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA03220701Medicare UPIN
PA532571Medicare UPIN