Provider Demographics
NPI:1184403438
Name:MAZZARELLA, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MAZZARELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 GREENE AVENUE
Mailing Address - Street 2:2R
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11216
Mailing Address - Country:US
Mailing Address - Phone:773-633-1977
Mailing Address - Fax:
Practice Address - Street 1:2139 ADAM CLAYTON POWELL JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3719
Practice Address - Country:US
Practice Address - Phone:773-633-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106H0000X1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical