Basic Information
| Provider Information | |||||||||
| NPI: | 1811137789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 EAST 86 STREET | ||||||||
| Address2: | #PHC | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124723672 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 WEST END AVE | ||||||||
| Address2: | 1C | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2009 | ||||||||
| LastUpdateDate: | 05/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 005651 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02298864 | 05 | NY | MEDICAID |