Provider Demographics
NPI:1235596099
Name:JACOBSEN, KELSEY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17196 FAWNDALE DR
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-6501
Mailing Address - Country:US
Mailing Address - Phone:408-219-9947
Mailing Address - Fax:
Practice Address - Street 1:17196 FAWNDALE DR
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-6501
Practice Address - Country:US
Practice Address - Phone:408-219-9947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22665235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist