Provider Demographics
NPI:1063402378
Name:VENTER, JACOB J (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:J
Last Name:VENTER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:CHA - PSYCHIATRY - ADOLESCENT ASSESSMENT UNIT
Mailing Address - Street 2:1493 CAMBRIDGE STREET
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139
Mailing Address - Country:US
Mailing Address - Phone:617-575-5460
Mailing Address - Fax:
Practice Address - Street 1:CHA - PSYCHIATRY - ADOLESCENT ASSESSMENT UNIT
Practice Address - Street 2:1493 CAMBRIDGE STREET
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-575-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ328122084P0804X
MA2100852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ25693OtherBCBS MA
MAS400413978OtherMEDICARE
MA110034921AMedicaid
MA459239OtherTUFTS HEALTH PLAN
AZ864430Medicaid
H50312Medicare UPIN