Provider Demographics
NPI:1861095697
Name:JACOBSEN, SUSAN MARIE (ATR-BC, LPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:ATR-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 DAFFODIL ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4151
Mailing Address - Country:US
Mailing Address - Phone:171-932-2463
Mailing Address - Fax:
Practice Address - Street 1:427 E COLORADO AVE # 219
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3601
Practice Address - Country:US
Practice Address - Phone:719-322-4630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4035101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional