Provider Demographics
NPI:1720317779
Name:BERGER, JACOB E (LMSW)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:E
Last Name:BERGER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 HENRY HUDSON PKWY APT 810
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-3811
Mailing Address - Country:US
Mailing Address - Phone:917-885-3424
Mailing Address - Fax:
Practice Address - Street 1:4525 HENRY HUDSON PKWY APT 810
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-3811
Practice Address - Country:US
Practice Address - Phone:917-885-3424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079744101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor