Provider Demographics
NPI:1316090483
Name:POMERANTZ, JACOB MARC (PHD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MARC
Last Name:POMERANTZ
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 1:8670 WOLFF CT
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-6956
Mailing Address - Country:US
Mailing Address - Phone:720-971-9369
Mailing Address - Fax:303-430-5306
Practice Address - Street 1:8670 WOLFF CT
Practice Address - Street 2:SUITE 130
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-6956
Practice Address - Country:US
Practice Address - Phone:720-971-9369
Practice Address - Fax:303-430-5306
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2064103G00000X, 103TC0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04142246Medicaid
CO07020647Medicaid
CO96026Medicare ID - Type Unspecified
CO07020647Medicaid