Provider Demographics
NPI:1497867014
Name:MEGDELL, JACOB I (PHD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:I
Last Name:MEGDELL
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 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:517-676-9788
Mailing Address - Fax:517-676-3438
Practice Address - Street 1:2422 JOLLY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3514
Practice Address - Country:US
Practice Address - Phone:517-347-6944
Practice Address - Fax:517-347-6912
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007262103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M54560Medicare ID - Type Unspecified