Provider Demographics
NPI:1619910825
Name:JACOBS, JOHN MCCORMICK (MSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MCCORMICK
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 EVIO JOHN CT
Mailing Address - Street 2:
Mailing Address - City:PALERMO
Mailing Address - State:NJ
Mailing Address - Zip Code:08223-1065
Mailing Address - Country:US
Mailing Address - Phone:609-390-9182
Mailing Address - Fax:
Practice Address - Street 1:76 JIMMY LEEDS ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205
Practice Address - Country:US
Practice Address - Phone:609-602-8933
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000287001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ640629Medicare ID - Type Unspecified