Provider Demographics
NPI:1336955244
Name:JACOBS, MALLORY (LISW-CP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WESTPARK BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-3871
Mailing Address - Country:US
Mailing Address - Phone:803-322-7895
Mailing Address - Fax:
Practice Address - Street 1:107 WESTPARK BLVD STE 140
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-3871
Practice Address - Country:US
Practice Address - Phone:803-322-7895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC174541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical