Provider Demographics
NPI:1295188159
Name:LACKOW, JACOB (MA)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:LACKOW
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2661
Mailing Address - Country:US
Mailing Address - Phone:646-625-4300
Mailing Address - Fax:
Practice Address - Street 1:101 E 56TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2661
Practice Address - Country:US
Practice Address - Phone:646-625-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program