Provider Demographics
NPI:1770633091
Name:JACOBY, STUART L (EDD)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:L
Last Name:JACOBY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 WALPOLE STREET
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-1626
Mailing Address - Country:US
Mailing Address - Phone:781-724-7468
Mailing Address - Fax:781-784-7671
Practice Address - Street 1:93 POND STREET
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:MA
Practice Address - Zip Code:02067-1626
Practice Address - Country:US
Practice Address - Phone:781-724-7468
Practice Address - Fax:781-784-7671
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7279103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05780OtherBCBS
MAW05780OtherBCBS