Provider Demographics
NPI:1164638946
Name:JACOBS, DAMON LANCE (LMFT)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:LANCE
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SECOND AVENUE
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:212-360-7893
Mailing Address - Fax:212-348-7253
Practice Address - Street 1:1900 SECOND AVENUE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-360-7893
Practice Address - Fax:212-348-7253
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000455106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist