Provider Demographics
NPI:1083753271
Name:JACOBS, MARTIN ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ALLEN
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CONCORD ROAD
Mailing Address - Street 2:PO BOX 95
Mailing Address - City:SUNBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01776-0095
Mailing Address - Country:US
Mailing Address - Phone:978-443-4601
Mailing Address - Fax:978-443-4602
Practice Address - Street 1:10 CONCORD ROAD
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:MA
Practice Address - Zip Code:01776-0095
Practice Address - Country:US
Practice Address - Phone:978-443-4601
Practice Address - Fax:978-443-4602
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA250103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJAWW0050OtherBLUESHIELD
MAJAWW005068Medicare ID - Type Unspecified