Provider Demographics
NPI:1831310473
Name:JACOBS, ED (PHD)
Entity Type:Individual
Prefix:DR
First Name:ED
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:STAR CITY
Mailing Address - State:WV
Mailing Address - Zip Code:26505
Mailing Address - Country:US
Mailing Address - Phone:304-599-0109
Mailing Address - Fax:304-599-6683
Practice Address - Street 1:457 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-599-0109
Practice Address - Fax:304-599-6683
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV650101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor