Healthcare Provider Details

I. General information

NPI: 1285415059
Provider Name (Legal Business Name): ELLEN MARIE JACOB LCSW, CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELLEN LONG LCSW, CDP

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 FALLS OF VENICE CIR
VENICE FL
34292-3979
US

IV. Provider business mailing address

11541 SHADY ACRES PATH
VENICE FL
34293-8140
US

V. Phone/Fax

Practice location:
  • Phone: 904-607-0160
  • Fax:
Mailing address:
  • Phone: 904-607-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number24099
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1881606
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.013646161TELE
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: