Provider Demographics
NPI:1144594466
Name:JACOBS, JUDY LYNN (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:LYNN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 CROOKS RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4733
Mailing Address - Country:US
Mailing Address - Phone:248-731-7305
Mailing Address - Fax:248-731-7388
Practice Address - Street 1:2525 CROOKS RD
Practice Address - Street 2:STE. 100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4733
Practice Address - Country:US
Practice Address - Phone:248-731-7305
Practice Address - Fax:248-731-7388
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012194101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional