Provider Demographics
NPI:1427129691
Name:JACOBS, BRADFORD ELLIOT (PHD)
Entity type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:ELLIOT
Last Name:JACOBS
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 1:30 HEMPSTEAD AVE
Mailing Address - Street 2:SUITE 143
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4033
Mailing Address - Country:US
Mailing Address - Phone:516-764-3223
Mailing Address - Fax:877-546-7612
Practice Address - Street 1:30 HEMPSTEAD AVE
Practice Address - Street 2:SUITE 143
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4033
Practice Address - Country:US
Practice Address - Phone:516-764-3223
Practice Address - Fax:877-546-7612
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8097103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV40682Medicare PIN