Provider Demographics
NPI:1447600754
Name:JACOBS, LAURIE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20277 DAWSON MILL PL
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-8807
Mailing Address - Country:US
Mailing Address - Phone:703-407-3835
Mailing Address - Fax:
Practice Address - Street 1:24600 MILLSTREAM DR
Practice Address - Street 2:SUITE 340
Practice Address - City:STONE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:20105-5685
Practice Address - Country:US
Practice Address - Phone:703-327-0335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202002736235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist