Provider Demographics
NPI:1720688278
Name:JACOBS, KIMBERLY MICHELLE (MFTT CT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MFTT CT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1217
Mailing Address - Country:US
Mailing Address - Phone:440-234-2006
Mailing Address - Fax:
Practice Address - Street 1:1433 5TH ST NW
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-1223
Practice Address - Country:US
Practice Address - Phone:440-260-5830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2002358-TRNE101Y00000X
OHM.2000185-TRNE106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor