Provider Demographics
NPI:1467675819
Name:JACOB, SUSAN VIVIAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:VIVIAN
Last Name:JACOB
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:VIVIAN
Other - Last Name:JAKOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DOCTORATE
Mailing Address - Street 1:14 VANDERVENTER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3737
Mailing Address - Country:US
Mailing Address - Phone:516-944-3786
Mailing Address - Fax:
Practice Address - Street 1:14 VANDERVENTER AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3737
Practice Address - Country:US
Practice Address - Phone:516-944-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0077981103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0077981OtherLICENSE NUMBER