Provider Demographics
NPI:1508169780
Name:JACOBS, RICHARD JOHN (LMSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOHN
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 ASHLEY RD
Mailing Address - Street 2:
Mailing Address - City:MAINE
Mailing Address - State:NY
Mailing Address - Zip Code:13802-1032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:164 HAWLEY ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-4017
Practice Address - Country:US
Practice Address - Phone:607-762-6416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-10
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0555691041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool