Provider Demographics
NPI:1104548957
Name:JACOBSON, ASHLEY NICOLE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 3RD AVE S APT 278
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4186
Mailing Address - Country:US
Mailing Address - Phone:352-989-0891
Mailing Address - Fax:
Practice Address - Street 1:9887 4TH ST N STE 319
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-8445
Practice Address - Country:US
Practice Address - Phone:727-490-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY12361103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist