Provider Demographics
NPI:1417243767
Name:JACOBS, LYNN MARIE (MS LLP)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MS LLP
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS LLP
Mailing Address - Street 1:E. 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067
Mailing Address - Country:US
Mailing Address - Phone:248-607-0793
Mailing Address - Fax:
Practice Address - Street 1:618 E 11 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1962
Practice Address - Country:US
Practice Address - Phone:248-607-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014502103TC0700X, 101YM0800X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent