Provider Demographics
NPI:1447876354
Name:JACOB, ASHLEY MARIAM (PSYD)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIAM
Last Name:JACOB
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25729 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3856
Mailing Address - Country:US
Mailing Address - Phone:586-879-5953
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4400
Practice Address - Country:US
Practice Address - Phone:248-787-3831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301019377103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical