Provider Demographics
NPI:1346469293
Name:JACOBS, EDITH CLAIRE (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:CLAIRE
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 1:406 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209
Mailing Address - Country:US
Mailing Address - Phone:716-886-7304
Mailing Address - Fax:716-886-7398
Practice Address - Street 1:406 LINWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209
Practice Address - Country:US
Practice Address - Phone:716-886-7304
Practice Address - Fax:716-886-7398
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009157103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02103753Medicaid
281847Medicare ID - Type Unspecified