Provider Demographics
NPI:1447352802
Name:JACOBSEN, JR., LARRY JAMES (MA, LMFT)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JAMES
Last Name:JACOBSEN, JR.
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:MR
Other - First Name:JIM
Other - Middle Name:
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LMFT
Mailing Address - Street 1:1775 E PALM CANYON DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9890 COUNTY FARM RD STE 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3678
Practice Address - Country:US
Practice Address - Phone:951-509-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 42093106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist