Provider Demographics
NPI:1225587686
Name:JACOBS, LARA ILYSSE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:ILYSSE
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 1:23 HOFFMAN ST
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-1113
Mailing Address - Country:US
Mailing Address - Phone:212-851-6231
Mailing Address - Fax:
Practice Address - Street 1:23 HOFFMAN ST
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-1113
Practice Address - Country:US
Practice Address - Phone:212-851-6231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00600100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist