Provider Demographics
NPI:1811670375
Name:BORDOLEY, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BORDOLEY
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 1:244 5TH AVE STE 2586
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-7604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:244 5TH AVE STE 2586
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7604
Practice Address - Country:US
Practice Address - Phone:347-991-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-P123324-01101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor