Provider Demographics
NPI:1508652041
Name:ELMER, JACOB DAVID
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DAVID
Last Name:ELMER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 WENONAH PL APT 3
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-1965
Mailing Address - Country:US
Mailing Address - Phone:315-767-9663
Mailing Address - Fax:
Practice Address - Street 1:5841 CORPORATE WAY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2039
Practice Address - Country:US
Practice Address - Phone:561-328-8643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-429749106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician