Provider Demographics
NPI:1417035874
Name:JACOB, MICHELLE (CASAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 BAILEY AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-2814
Mailing Address - Country:US
Mailing Address - Phone:716-831-1800
Mailing Address - Fax:716-831-1818
Practice Address - Street 1:6520 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-1550
Practice Address - Country:US
Practice Address - Phone:716-831-1840
Practice Address - Fax:716-831-1839
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8370101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8370OtherCASAC