Provider Demographics
NPI:1003177882
Name:JACOBS, LORI DIAMOND (MSED)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:DIAMOND
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 KNAPP ST
Mailing Address - Street 2:5A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5766
Mailing Address - Country:US
Mailing Address - Phone:718-382-9810
Mailing Address - Fax:
Practice Address - Street 1:420 95TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7404
Practice Address - Country:US
Practice Address - Phone:718-680-9751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY509850041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist