Provider Demographics
NPI:1780645556
Name:JACOBSEN, AMANDA JEAN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:JACOBSEN
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Gender:F
Credentials:MA, CCC-SLP
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:43 NEW SCOTLAND AVE
Mailing Address - Street 2:COMMUNICATION DISORDERS DEPARTMENT, MC-128
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3412
Mailing Address - Country:US
Mailing Address - Phone:518-262-4526
Mailing Address - Fax:518-262-6896
Practice Address - Street 1:43 NEW SCOTLAND AVE
Practice Address - Street 2:COMMUNICATION DISORDERS DEPARTMENT, MC-128
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-4526
Practice Address - Fax:518-262-6896
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2016-02-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY014269235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYOTH000Medicare UPIN
NYB82629Medicare ID - Type Unspecified