Provider Demographics
NPI:1659972974
Name:JACOBS, SHOSHANNAH BETH
Entity Type:Individual
Prefix:
First Name:SHOSHANNAH
Middle Name:BETH
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 SENIX AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934-2905
Mailing Address - Country:US
Mailing Address - Phone:631-767-2146
Mailing Address - Fax:
Practice Address - Street 1:1902 149TH ST
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-3116
Practice Address - Country:US
Practice Address - Phone:516-780-0770
Practice Address - Fax:718-764-1238
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician