Provider Demographics
NPI:1922146471
Name:JACOBS, RICHARD L (PSY D)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680A BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-2180
Mailing Address - Country:US
Mailing Address - Phone:617-734-5770
Mailing Address - Fax:617-734-0964
Practice Address - Street 1:1680A BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-2180
Practice Address - Country:US
Practice Address - Phone:617-734-5770
Practice Address - Fax:617-734-0964
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4089103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJAW03998Medicare ID - Type Unspecified