Provider Demographics
NPI:1891136883
Name:JACOBS, MARA ROBYN (LPC)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:ROBYN
Last Name:JACOBS
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 1:720 N SAINT ASAPH ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-1912
Mailing Address - Country:US
Mailing Address - Phone:703-746-3401
Mailing Address - Fax:703-746-3464
Practice Address - Street 1:720 N SAINT ASAPH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1912
Practice Address - Country:US
Practice Address - Phone:703-746-3401
Practice Address - Fax:703-746-3464
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004470101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447279658Medicaid