Provider Demographics
NPI:1831190792
Name:JACOBSEN, LEAH M (AUD, CCC-A)
Entity type:Individual
Prefix:DR
First Name:LEAH
Middle Name:M
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 11TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4849
Mailing Address - Country:US
Mailing Address - Phone:406-761-0611
Mailing Address - Fax:406-761-7972
Practice Address - Street 1:1701 11TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4849
Practice Address - Country:US
Practice Address - Phone:406-761-0611
Practice Address - Fax:406-761-7972
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTAU1077231H00000X
MTAU 1077237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT290618OtherBLUE CROSS BLUE SHIELD
MT1831190792OtherTRIWEST
MT1831190792Medicaid