Provider Demographics
NPI:1063922417
Name:JACOBY, RYANNE E (SSP, NCSP, MA)
Entity type:Individual
Prefix:MRS
First Name:RYANNE
Middle Name:E
Last Name:JACOBY
Suffix:
Gender:F
Credentials:SSP, NCSP, MA
Other - Prefix:MISS
Other - First Name:RYANNE
Other - Middle Name:E
Other - Last Name:NASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SSP, NCSP, MA
Mailing Address - Street 1:210 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:IL
Mailing Address - Zip Code:62321-1420
Mailing Address - Country:US
Mailing Address - Phone:217-357-9202
Mailing Address - Fax:217-357-3755
Practice Address - Street 1:600 MILLER ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:IL
Practice Address - Zip Code:62321-1129
Practice Address - Country:US
Practice Address - Phone:217-357-2136
Practice Address - Fax:217-357-3569
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2351336103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1063922417Medicaid