Provider Demographics
NPI:1144532078
Name:JACOBSON, JESSICA ANN (MED, LPC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:ROMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:968 ROCK FOREST WAY
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-4509
Mailing Address - Country:US
Mailing Address - Phone:803-701-0075
Mailing Address - Fax:
Practice Address - Street 1:302 TOM HALL ST
Practice Address - Street 2:SUITE 5
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-2338
Practice Address - Country:US
Practice Address - Phone:803-701-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2016-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101Y00000X
NC9517101YP2500X
SC5624101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor