Provider Demographics
NPI:1356333678
Name:JACOBS, CECILIA (PSYD)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2188 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6356
Mailing Address - Country:US
Mailing Address - Phone:937-320-5859
Mailing Address - Fax:937-426-1349
Practice Address - Street 1:2188 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6356
Practice Address - Country:US
Practice Address - Phone:937-320-5859
Practice Address - Fax:937-426-1349
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5332103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHJACP21112Medicare ID - Type Unspecified