Provider Demographics
NPI:1922185479
Name:AZERRAD, JACOB (PHD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:AZERRAD
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 1:19 MUZZEY ST
Mailing Address - Street 2:P.O. BOX 353, SUITE 310
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-5256
Mailing Address - Country:US
Mailing Address - Phone:781-861-8637
Mailing Address - Fax:
Practice Address - Street 1:19 MUZZEY ST
Practice Address - Street 2:SUITE 310
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-5256
Practice Address - Country:US
Practice Address - Phone:781-861-8637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA915101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health