Provider Demographics
NPI:1457197147
Name:JACOBS, CHRISTINA LEE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:LEE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:LEE
Other - Last Name:MCCUTCHEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2198 NE STEPHENS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1410
Mailing Address - Country:US
Mailing Address - Phone:541-900-1418
Mailing Address - Fax:
Practice Address - Street 1:2198 NE STEPHENS ST STE 101
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1410
Practice Address - Country:US
Practice Address - Phone:541-900-1418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR016234235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist