Provider Demographics
NPI:1487615332
Name:JACOBSON, AUDREY D (LCSW)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:D
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 SAW MILL RIVER RD
Mailing Address - Street 2:STE 7
Mailing Address - City:ARDSLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10502
Mailing Address - Country:US
Mailing Address - Phone:914-693-5463
Mailing Address - Fax:914-674-2811
Practice Address - Street 1:731 SAW MILL RIVER RD
Practice Address - Street 2:STE 7
Practice Address - City:ARDSLEY
Practice Address - State:NY
Practice Address - Zip Code:10502
Practice Address - Country:US
Practice Address - Phone:914-693-5463
Practice Address - Fax:914-674-2811
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03687411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN53132Medicare ID - Type Unspecified