Provider Demographics
NPI:1285232124
Name:JACOB, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:JACOB
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:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:FREDERIKSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00841-0392
Mailing Address - Country:US
Mailing Address - Phone:917-569-8303
Mailing Address - Fax:
Practice Address - Street 1:24X STONEY GROUND
Practice Address - Street 2:
Practice Address - City:FREDERIKSTED
Practice Address - State:VI
Practice Address - Zip Code:00841
Practice Address - Country:US
Practice Address - Phone:917-569-8303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1207104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker