Provider Demographics
NPI:1992923635
Name:JACOBS, KIAN FAY (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIAN
Middle Name:FAY
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:108 TIMBERLINE TRAIL
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4925
Mailing Address - Country:US
Mailing Address - Phone:860-817-3175
Mailing Address - Fax:386-281-5091
Practice Address - Street 1:17 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-2405
Practice Address - Country:US
Practice Address - Phone:860-817-3175
Practice Address - Fax:386-236-9000
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0063881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT006388OtherDEPARTMENT OF PUBLIC HEALTH
CT006388OtherCT LICENSE