Provider Demographics
NPI:1568845188
Name:JACOBY, CAROLYN M (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:JACOBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 S THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-5733
Mailing Address - Country:US
Mailing Address - Phone:941-600-6656
Mailing Address - Fax:
Practice Address - Street 1:4850 S THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408
Practice Address - Country:US
Practice Address - Phone:941-600-6656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW115741041C0700X
WALW606143211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW11574OtherLCSW
WALW60614321OtherLICSW