Healthcare Provider Details

I. General information

NPI: 1578178901
Provider Name (Legal Business Name): ASHLYN MICHELLE JACOB LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 S MAIN ST STE 202
MOUNT AIRY MD
21771-5457
US

IV. Provider business mailing address

1311 S MAIN ST STE 202
MOUNT AIRY MD
21771-5457
US

V. Phone/Fax

Practice location:
  • Phone: 301-829-2242
  • Fax: 833-449-5168
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0904019733
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number26320
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26320
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: