Provider Demographics
NPI:1023231032
Name:JACOBSON, KELLY B (PHD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:B
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 LEE RD
Mailing Address - Street 2:SUITE 234
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2115
Mailing Address - Country:US
Mailing Address - Phone:407-678-0100
Mailing Address - Fax:
Practice Address - Street 1:1850 LEE RD
Practice Address - Street 2:SUITE 234
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2115
Practice Address - Country:US
Practice Address - Phone:407-678-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 0007292103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling