Provider Demographics
NPI:1659846285
Name:JACOBS, JERRY (LICSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-3517
Mailing Address - Country:US
Mailing Address - Phone:781-453-1945
Mailing Address - Fax:
Practice Address - Street 1:17 MELROSE AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-3517
Practice Address - Country:US
Practice Address - Phone:781-453-1945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102343SW-LICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical