Provider Demographics
NPI:1588767768
Name:JACOBS, ANN LIEBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:ANN
Middle Name:LIEBERT
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 HONEYSUCKLE ROAD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305
Mailing Address - Country:US
Mailing Address - Phone:334-794-5467
Mailing Address - Fax:334-677-1051
Practice Address - Street 1:256 HONEYSUCKLE ROAD
Practice Address - Street 2:SUITE 14
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305
Practice Address - Country:US
Practice Address - Phone:334-794-5467
Practice Address - Fax:334-677-1051
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL321103T00000X
GA000928103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBFFVOtherMEDICARE
R35815Medicare ID - Type Unspecified
GA68BBFFVOtherMEDICARE