Provider Demographics
NPI:1821755232
Name:VAN DIJK, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VAN DIJK
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 1:51 BELLROSE RD
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-1324
Mailing Address - Country:US
Mailing Address - Phone:757-768-2761
Mailing Address - Fax:
Practice Address - Street 1:28 N COUNTRY RD STE 203
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-1518
Practice Address - Country:US
Practice Address - Phone:888-975-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110561104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker