Provider Demographics
NPI:1790916161
Name:JACOBY, WADE STEWART (LSW)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:STEWART
Last Name:JACOBY
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PENN STREET
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331
Mailing Address - Country:US
Mailing Address - Phone:717-632-0774
Mailing Address - Fax:717-633-5816
Practice Address - Street 1:112 CLOVER LANE
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331
Practice Address - Country:US
Practice Address - Phone:717-632-0774
Practice Address - Fax:717-633-5816
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW127361104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker