Provider Demographics
NPI:1174256135
Name:GOYCO, JACOB A
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:GOYCO
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 1:17 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1093
Mailing Address - Country:US
Mailing Address - Phone:315-705-6564
Mailing Address - Fax:
Practice Address - Street 1:17 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1093
Practice Address - Country:US
Practice Address - Phone:315-705-6564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY141536222OtherWORK