MEDICARE: MS. ELLEN MARIE JACOB LCSW, CDP

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	1041C0700X	Clinical Social Worker	24099	FL
2	1041C0700X	Clinical Social Worker	1881606	ID
3	1041C0700X	Clinical Social Worker	089.013646161TELE	VT

General Provider Information

NPI Number	:	1285415059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELLEN MARIE JACOB LCSW, CDP

Provider Business Mailing Address
First Line	:	11541 SHADY ACRES PATH
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34293-8140
Country	:	US
Telephone Number	:	904-607-0160
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 FALLS OF VENICE CIR
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34292-3979
Country	:	US
Telephone Number	:	904-607-0160
Fax Number	:

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

Provider Enumeration Date	:	10/09/2023
Last Update Date	:	05/28/2026

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