Provider Demographics
NPI:1508992173
Name:JACOBSON, JOHN RUSSELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSELL
Last Name:JACOBSON
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 1:14 ACORN DR
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-1302
Mailing Address - Country:US
Mailing Address - Phone:631-754-5892
Mailing Address - Fax:
Practice Address - Street 1:14 ACORN DR
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-1302
Practice Address - Country:US
Practice Address - Phone:631-754-5892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008596-1251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)