Basic Information
| Provider Information | |||||||||
| NPI: | 1316300387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | CORAL | ||||||||
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| Credential: | PLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1106 N 155TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | BASEHOR | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660077100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136627071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 S 36TH ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163966002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2016 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TF0000X | 2848 | KS | N | Behavioral Health & Social Service Providers | Psychologist | Family | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | 2021022398 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 2021022398 | 01 | MO | PROFESSIONAL COUNSELING | OTHER |