Provider Demographics
NPI:1174648232
Name:JACOBY, JACOB H (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:H
Last Name:JACOBY
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 AVE C
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002
Mailing Address - Country:US
Mailing Address - Phone:201-339-0323
Mailing Address - Fax:201-339-0349
Practice Address - Street 1:654 AVE C
Practice Address - Street 2:SUITE 201
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002
Practice Address - Country:US
Practice Address - Phone:201-339-0323
Practice Address - Fax:201-339-0349
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ462592084A0401X, 2084P0800X
NY156653-12084A0401X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY088BV1OtherMEDICARE
E58672Medicare UPIN
NJJA511806Medicare ID - Type Unspecified