Stacia Jacobson-Gray, LPCC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

CC01218 Issued in MN

Practice address

3395 Plymouth Rd
Minnetonka, MN 55305-3765

Phone

(952) 939-0396

Fax

(952) 548-8760

NPI assigned

Feb 18, 2011

Last updated

May 16, 2016By the provider in NPPES

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

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

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Wild Tree Psychotherapy, LLC

  • Community/Behavioral Health Agency
  • Saint Paul, MN
  • NPI 1528451408
  Medicare reassignment NPD
• Sarah C. Chambers, P.a.

  dba Crocus Hill Health Center

  • Health Service Clinic/Center
  • Saint Paul, MN
  • NPI 1942358379
  NPD (past)

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

{
    "created_epoch": "1297987200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1463356800000",
    "number": "1457658981",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3395 PLYMOUTH RD",
            "city": "MINNETONKA",
            "state": "MN",
            "postal_code": "553053765",
            "telephone_number": "952-939-0396",
            "fax_number": "952-548-8760"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3395 PLYMOUTH RD",
            "city": "MINNETONKA",
            "state": "MN",
            "postal_code": "553053765",
            "telephone_number": "952-939-0396",
            "fax_number": "952-548-8760"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACOBSON-GRAY",
        "first_name": "STACIA",
        "credential": "LPCC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-02-18",
        "last_updated": "2016-05-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "MN",
            "license": "CC01218",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Prema Padachira Jacob, ANP
• Patricia Jacobs-Mann, ARNP
• Cory D Jacobs, DC, PA-C
• Harlie Jo Jacobsen
• Kristine Jacobsen, REGISTERED NURSE
• Andrew Jacobson
• Jacquelyn K. Wiersma, PH. D., LP, PLLC
• Hannah Jaeger, LPCC
• Abass Jafuneh, APRN, PMHNP-BC
• Malika Tapree Jager

• Professional Counselor in Minnetonka, MN
• Providers in Minnetonka, MN by specialty
• Professional Counselor in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 16, 2016; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.