Provider Demographics
NPI:1447997002
Name:JACOBS, LOGAN (MSW)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 VONDERBURG DR STE 301
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6072
Mailing Address - Country:US
Mailing Address - Phone:813-881-1000
Mailing Address - Fax:
Practice Address - Street 1:510 VONDERBURG DR STE 301
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6072
Practice Address - Country:US
Practice Address - Phone:813-881-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW17410101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)