Provider Demographics
NPI:1700164977
Name:JACOBSON, KELLY ASWAD (SP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ASWAD
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 JOHN ROLFE PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-8110
Mailing Address - Country:US
Mailing Address - Phone:804-750-2183
Mailing Address - Fax:804-750-1078
Practice Address - Street 1:1600 JOHN ROLFE PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-8110
Practice Address - Country:US
Practice Address - Phone:804-750-2183
Practice Address - Fax:804-750-1078
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist