Provider Demographics
NPI:1922148832
Name:JACOBSON WISE, NAN (MSW)
Entity Type:Individual
Prefix:MS
First Name:NAN
Middle Name:
Last Name:JACOBSON WISE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 VILLAGE PLZ
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2818
Mailing Address - Country:US
Mailing Address - Phone:973-632-0625
Mailing Address - Fax:
Practice Address - Street 1:15 VILLAGE PLZ
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2818
Practice Address - Country:US
Practice Address - Phone:973-632-0625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC001870001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical