Provider Demographics
NPI:1114573292
Name:JACOBS-JOHNSON, MCKINZIE SHAE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MCKINZIE
Middle Name:SHAE
Last Name:JACOBS-JOHNSON
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 1:4421 OLD SALEM RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2698
Mailing Address - Country:US
Mailing Address - Phone:937-832-6800
Mailing Address - Fax:
Practice Address - Street 1:4421 OLD SALEM RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2698
Practice Address - Country:US
Practice Address - Phone:937-832-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13618235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist