Provider Demographics
NPI:1740218494
Name:JACOB, MELVIN R
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:R
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S ORLANDO AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5547
Mailing Address - Country:US
Mailing Address - Phone:407-644-4692
Mailing Address - Fax:
Practice Address - Street 1:1600 S ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-5547
Practice Address - Country:US
Practice Address - Phone:407-644-4692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT 1127106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist