Provider Demographics
NPI:1548493760
Name:JACOBSON PURA, KRISTIN KELI (PSYD, ABPP)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:KELI
Last Name:JACOBSON PURA
Suffix:
Gender:F
Credentials:PSYD, ABPP
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:KELI
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD, ABPP
Mailing Address - Street 1:2185 W GRANT LINE RD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7309
Mailing Address - Country:US
Mailing Address - Phone:209-839-6282
Mailing Address - Fax:
Practice Address - Street 1:2185 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7309
Practice Address - Country:US
Practice Address - Phone:209-839-6282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26477103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist