Provider Demographics
NPI:1922180561
Name:KIRSCHENBAUM, JACOB (PHD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KIRSCHENBAUM
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 1:315A FORSGATE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-1539
Mailing Address - Country:US
Mailing Address - Phone:732-521-3600
Mailing Address - Fax:732-521-3603
Practice Address - Street 1:315A FORSGATE DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NJ
Practice Address - Zip Code:08831-1539
Practice Address - Country:US
Practice Address - Phone:732-521-3600
Practice Address - Fax:732-521-3603
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2015-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100218900103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KI 189195Medicare ID - Type Unspecified