Provider Demographics
NPI:1750646063
Name:JACOB, SHARI I (MA)
Entity type:Individual
Prefix:
First Name:SHARI
Middle Name:
Last Name:JACOB
Suffix:I
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SHARI
Other - Middle Name:
Other - Last Name:GOKOOL
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:12512 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9209
Mailing Address - Country:US
Mailing Address - Phone:813-977-8700
Mailing Address - Fax:
Practice Address - Street 1:12512 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9209
Practice Address - Country:US
Practice Address - Phone:813-977-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 10005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health