Provider Demographics
NPI:1578097051
Name:JACOBY, FRED JR (MA)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:JACOBY
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1546 ROUTE 209
Mailing Address - Street 2:STE 106
Mailing Address - City:BRODHEADSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18322-7142
Mailing Address - Country:US
Mailing Address - Phone:570-402-5088
Mailing Address - Fax:
Practice Address - Street 1:1546 ROUTE 209
Practice Address - Street 2:STE 106
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-7142
Practice Address - Country:US
Practice Address - Phone:570-402-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional