Provider Demographics
NPI:1063980068
Name:THORNTON, JACOB D (MHC-LIMITED PERMIT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:THORNTON
Suffix:
Gender:M
Credentials:MHC-LIMITED PERMIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 75TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1427
Mailing Address - Country:US
Mailing Address - Phone:347-448-4770
Mailing Address - Fax:718-350-3072
Practice Address - Street 1:2626 75TH ST
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1427
Practice Address - Country:US
Practice Address - Phone:347-448-4770
Practice Address - Fax:718-350-3072
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP10428101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health