Provider Demographics
NPI:1003589433
Name:ABRAHAM, JACOB ANDREW
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANDREW
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14220-1310
Mailing Address - Country:US
Mailing Address - Phone:716-931-0141
Mailing Address - Fax:
Practice Address - Street 1:387 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1507
Practice Address - Country:US
Practice Address - Phone:716-462-0284
Practice Address - Fax:716-262-0481
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP105172101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health