Provider Demographics
NPI:1316954258
Name:JACOB, MATHEW (PH D)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 EAST 33RD STREET
Mailing Address - Street 2:SUITE 31J
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:914-946-4700
Mailing Address - Fax:914-285-5723
Practice Address - Street 1:200 EAST 33RD STREET
Practice Address - Street 2:SUITE 31J
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:914-946-4700
Practice Address - Fax:914-285-5723
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014786-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist