Provider Demographics
NPI:1154530103
Name:JACOBS, ELIZABETH D (MA CCCSLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:D
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:BETSEY
Other - Middle Name:
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2025 GREEN LEAF RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99725-6273
Mailing Address - Country:US
Mailing Address - Phone:907-451-1067
Mailing Address - Fax:
Practice Address - Street 1:600 UNIVERSITY AVE
Practice Address - Street 2:STE. 110
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3643
Practice Address - Country:US
Practice Address - Phone:907-451-1067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK155235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist