Provider Demographics
NPI:1861073322
Name:JACOBSON, HOLLY (PMHNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16353 BARNESTON ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-3017
Mailing Address - Country:US
Mailing Address - Phone:818-913-2075
Mailing Address - Fax:
Practice Address - Street 1:893 PATRIOT DR STE A
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3357
Practice Address - Country:US
Practice Address - Phone:805-531-1000
Practice Address - Fax:805-531-1100
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA547154363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty