Provider Demographics
NPI:1013780501
Name:GANZ, JACOB (LMHC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GANZ
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8523 125TH ST
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3310
Mailing Address - Country:US
Mailing Address - Phone:718-419-0908
Mailing Address - Fax:
Practice Address - Street 1:8523 125TH ST
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3310
Practice Address - Country:US
Practice Address - Phone:718-419-0908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014040101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health