Provider Demographics
NPI:1730891763
Name:JACOBSON, BRAE DAVENE (LPC)
Entity type:Individual
Prefix:
First Name:BRAE
Middle Name:DAVENE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10114 SUNFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1924
Mailing Address - Country:US
Mailing Address - Phone:512-540-1810
Mailing Address - Fax:
Practice Address - Street 1:10114 SUNFLOWER LN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1924
Practice Address - Country:US
Practice Address - Phone:512-540-1810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10319101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health