Provider Demographics
NPI:1881655751
Name:JACOB, DAVID G (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:JACOB
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 ESSEX PL
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5850
Mailing Address - Country:US
Mailing Address - Phone:203-377-3600
Mailing Address - Fax:
Practice Address - Street 1:1129 ESSEX PL
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5850
Practice Address - Country:US
Practice Address - Phone:203-377-3600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0023921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140002392CT01OtherANTHEM