Provider Demographics
NPI:1568985505
Name:JACOBY, KATIE LYNNE (LPC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNNE
Last Name:JACOBY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 MCDANIEL AVE
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-1238
Mailing Address - Country:US
Mailing Address - Phone:330-771-7034
Mailing Address - Fax:
Practice Address - Street 1:960 W STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4685
Practice Address - Country:US
Practice Address - Phone:330-771-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161912101YA0400X
OHC2103116101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH414018Medicaid