Provider Demographics
NPI:1700421302
Name:JACOBSON, MOLLY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2064 WOODBURY AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2808
Mailing Address - Country:US
Mailing Address - Phone:603-433-4192
Mailing Address - Fax:603-433-3381
Practice Address - Street 1:2064 WOODBURY AVE STE 204
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:NH
Practice Address - Zip Code:03801-2808
Practice Address - Country:US
Practice Address - Phone:603-433-4192
Practice Address - Fax:603-433-3381
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1947235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist