Provider Demographics
NPI:1063600195
Name:JACOB, CHARLES JASON (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JASON
Last Name:JACOB
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 1:8200 FLOURTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WYNDMOOR
Mailing Address - State:PA
Mailing Address - Zip Code:19038-7976
Mailing Address - Country:US
Mailing Address - Phone:215-233-3994
Mailing Address - Fax:
Practice Address - Street 1:33 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4406
Practice Address - Country:US
Practice Address - Phone:412-596-3870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017732103T00000X
CT001731101YP2500X
PAMF000509106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional