Provider Demographics
NPI:1609391564
Name:JACOBSEN, MATTHEW COLE (CSW-PIP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:COLE
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:CSW-PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 MDG
Mailing Address - Street 2:UNIT 5071
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96328
Mailing Address - Country:JP
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374 MDG
Practice Address - Street 2:UNIT 5071
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328
Practice Address - Country:JP
Practice Address - Phone:315-225-8864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5034104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker