Provider Demographics
NPI:1093194680
Name:JACOBS, KRISTEN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589
Mailing Address - Country:US
Mailing Address - Phone:585-727-3220
Mailing Address - Fax:
Practice Address - Street 1:4309 LAKE ROAD
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589
Practice Address - Country:US
Practice Address - Phone:585-727-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.10846235Z00000X
NY032011235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810029100Medicaid
OH0131743Medicaid
WV3810029100Medicaid