Provider Demographics
NPI:1134532245
Name:JACOBSON, AMY (AUD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 BEASER AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3604
Mailing Address - Country:US
Mailing Address - Phone:715-682-9311
Mailing Address - Fax:715-682-9313
Practice Address - Street 1:1901 BEASER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3604
Practice Address - Country:US
Practice Address - Phone:715-682-9311
Practice Address - Fax:715-682-9313
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI591-156231HA2400X, 231HA2500X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1134532245Medicaid