Provider Demographics
NPI:1053507566
Name:MARVEN WALLEN & S. KENNETH JACOBSON, MD PA
Entity Type:Organization
Organization Name:MARVEN WALLEN & S. KENNETH JACOBSON, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVEN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-763-5010
Mailing Address - Street 1:1985 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3435
Mailing Address - Country:US
Mailing Address - Phone:973-763-5010
Mailing Address - Fax:973-761-6980
Practice Address - Street 1:1985 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3435
Practice Address - Country:US
Practice Address - Phone:973-763-5010
Practice Address - Fax:973-761-6980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ458234Medicare PIN