Provider Demographics
NPI:1619136173
Name:JACOBS, PAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:JACOBS
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 1:1 HORIZON RD
Mailing Address - Street 2:APT. 1423
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6502
Mailing Address - Country:US
Mailing Address - Phone:954-563-9954
Mailing Address - Fax:
Practice Address - Street 1:1 HORIZON RD
Practice Address - Street 2:APT. 1423
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6502
Practice Address - Country:US
Practice Address - Phone:954-563-9954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5128103TC0700X
NJ35SI00481500103TC0700X
NY018887103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59646Medicare UPIN