Provider Demographics
NPI:1336496983
Name:HADDEN, JACOB EDWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EDWARD
Last Name:HADDEN
Suffix:
Gender:M
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 1202
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:NY
Mailing Address - Zip Code:12946-5202
Mailing Address - Country:US
Mailing Address - Phone:518-588-5173
Mailing Address - Fax:845-205-4454
Practice Address - Street 1:2038 SARANAC AVE
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:NY
Practice Address - Zip Code:12946-1177
Practice Address - Country:US
Practice Address - Phone:518-588-5173
Practice Address - Fax:845-205-4454
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016726-1103TC0700X
VT048.0092013103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical