Provider Demographics
NPI:1316133382
Name:JACOBS, BERTHA ELIZABETH (LCSW R)
Entity type:Individual
Prefix:MS
First Name:BERTHA
Middle Name:ELIZABETH
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:BERTHA
Other - Middle Name:ELIZABETH BYNOE
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW R
Mailing Address - Street 1:226 RANDOLPH STREET
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205
Mailing Address - Country:US
Mailing Address - Phone:315-492-6094
Mailing Address - Fax:
Practice Address - Street 1:226 RANDOLPH STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205
Practice Address - Country:US
Practice Address - Phone:315-492-6094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0368431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical