Provider Demographics
NPI:1215607585
Name:JACOBS, CARLY K (AUD)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:K
Last Name:JACOBS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S INDEPENDENCE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1126
Mailing Address - Country:US
Mailing Address - Phone:757-304-8445
Mailing Address - Fax:757-568-7634
Practice Address - Street 1:441 S INDEPENDENCE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1126
Practice Address - Country:US
Practice Address - Phone:757-304-8445
Practice Address - Fax:757-568-7634
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1968231H00000X
VA2201001910231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist