MEDICARE: CECILIA JACOBS PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	5332	OH

General Provider Information

NPI Number	:	1356333678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CECILIA JACOBS PSY.D.

Provider Business Mailing Address
First Line	:	2188 GATEWAY DR
Second Line	:
City	:	FAIRBORN
State	:	OH
Zip	:	45324-6356
Country	:	US
Telephone Number	:	937-320-5859
Fax Number	:	937-426-1349

Provider Business Practice Location Address
First Line	:	2188 GATEWAY DR
Second Line	:
City	:	FAIRBORN
State	:	OH
Zip	:	45324-6356
Country	:	US
Telephone Number	:	937-320-5859
Fax Number	:	937-426-1349

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	03/27/2008

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