Provider Demographics
NPI:1841375631
Name:JACOBS, MARTIN (PHD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598
Mailing Address - Country:US
Mailing Address - Phone:516-569-3535
Mailing Address - Fax:
Practice Address - Street 1:713 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598
Practice Address - Country:US
Practice Address - Phone:516-569-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYSTATE011021103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist