Provider Demographics
NPI:1225169493
Name:JACOBS, BONNIE (PHD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
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:PO BOX 826
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-0636
Mailing Address - Country:US
Mailing Address - Phone:631-444-2938
Mailing Address - Fax:
Practice Address - Street 1:15 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-3215
Practice Address - Country:US
Practice Address - Phone:631-444-2938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010569103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist