Provider Demographics
NPI:1861947574
Name:JACOBS, KRISTINE M (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:MICHELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:MS 958
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:8800 WASHINGTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-3701
Practice Address - Country:US
Practice Address - Phone:262-633-3591
Practice Address - Fax:262-633-2619
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8333-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical