Mary Lou Jacobsen, MSSW, LICSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

8206 Issued in MN

Practice address

610 Florence Ave
Owatonna, MN 55060-4704

Phone

(507) 451-2630

Fax

(507) 455-8133

NPI assigned

Oct 12, 2006

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 5

Other names 1

• Mary Lou Wagoner Former name

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Social Worker

Education

Other, 1991

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160611200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1612915200000",
    "number": "1295824696",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "610 FLORENCE AVE",
            "city": "OWATONNA",
            "state": "MN",
            "postal_code": "550604704"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "610 FLORENCE AVE",
            "city": "OWATONNA",
            "state": "MN",
            "postal_code": "550604704",
            "telephone_number": "507-451-2630",
            "fax_number": "507-455-8133"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACOBSEN",
        "first_name": "MARY",
        "middle_name": "LOU",
        "credential": "MSSW, LICSW",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-10-12",
        "last_updated": "2021-02-10",
        "certification_date": "2021-02-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MN",
            "license": "8206",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "4G504WA",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE",
            "identifier": "118039",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED BEHAVIORAL HEALTH",
            "identifier": "62-20365",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "074027600",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH PARTNERS",
            "identifier": "HP20016",
            "state": "MN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "messagec@direct.schrc.com",
            "affiliation": "N",
            "address_1": "610 Florence Ave",
            "city": "Owatonna",
            "state": "MN",
            "country_code": "US",
            "postal_code": "550604704",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "first_name": "MARY",
            "last_name": "WAGONER",
            "middle_name": "LOU",
            "credential": "MSSW, LICSW",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Innovative Minds ABA of Minnesota, P.C.
• Mustafe Abdi Ismael
• David W Ivance, MD
• Jocelyn Iveland, PHARMD
• Jason Parker Jacobs, CAT, PT
• Kari M Jacott, LPCC
• Nasteho Jama
• Janessa Jandt, LICSW
• Jeffrey D Loveless DDS PA
• Jerald L Monson Jr OD

• Clinical Social Worker in Owatonna, MN
• Providers in Owatonna, MN by specialty
• Clinical Social Worker in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.