Provider Demographics
NPI:1215309281
Name:JACOBSEN, MOLLY ALYSSA (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:ALYSSA
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:MOLLY
Other - Middle Name:ALYSSA
Other - Last Name:LYONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:3700 W PLUM ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68522-9422
Mailing Address - Country:US
Mailing Address - Phone:308-940-2298
Mailing Address - Fax:
Practice Address - Street 1:5621 BRIAR ROSA DR APT 10
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-4949
Practice Address - Country:US
Practice Address - Phone:308-940-2298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1752235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist