Provider Demographics
NPI:1689732497
Name:ABRAHAM, JACOB T (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:T
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25 BLUE HERON ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02879
Mailing Address - Country:US
Mailing Address - Phone:401-783-1637
Mailing Address - Fax:
Practice Address - Street 1:24 SALT POND RD
Practice Address - Street 2:SUITE D-4
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4314
Practice Address - Country:US
Practice Address - Phone:401-789-3694
Practice Address - Fax:401-789-3748
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD090042084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007008459Medicare ID - Type Unspecified