Provider Demographics
NPI:1144479395
Name:JACOBSON, RYAN ANDREW
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ANDREW
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 1:1810 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-3492
Mailing Address - Country:US
Mailing Address - Phone:715-848-4884
Mailing Address - Fax:715-845-5385
Practice Address - Street 1:1810 N 2ND ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-3492
Practice Address - Country:US
Practice Address - Phone:715-848-4884
Practice Address - Fax:715-845-5385
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78952106H00000X
WI1094-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist