Basic Information
| Provider Information | |||||||||
| NPI: | 1457333791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | JOANNE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CCC SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 818 NEWTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574738016 | ||||||||
| FaxNumber: | 7574733580 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 NEWTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574738016 | ||||||||
| FaxNumber: | 7574733580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2202001616 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 330087 | 01 | ANTHEM BLUE CROSS | OTHER | 35062 | 01 | OPTIMA | OTHER | 9116460 | 01 | VA | MEDICAID DME | OTHER | 5990711 | 01 | AETNA | OTHER | 4980093 | 01 | CAQH | OTHER | 4980093 | 01 | VIRGINIA PREMIER HEALTH P | OTHER | 4980093 | 05 | VA | MEDICAID | 6400313 | 01 | UNITED HEALTH CARE | OTHER | 95324397 | 01 | TRICARE CHAMPUS | OTHER |