Provider Demographics
NPI:1417397043
Name:JACOBSON, ALYSSA Y (MS)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:Y
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20413 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-7357
Mailing Address - Country:US
Mailing Address - Phone:229-548-7081
Mailing Address - Fax:
Practice Address - Street 1:724 PINE ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1654
Practice Address - Country:US
Practice Address - Phone:208-263-1843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP2404235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist