Provider Demographics
NPI:1528087855
Name:SMALL, JACOB ETHAN (PHD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ETHAN
Last Name:SMALL
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 1:286 MADISON AVENUE
Mailing Address - Street 2:SUITE 1602
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017
Mailing Address - Country:US
Mailing Address - Phone:917-704-3761
Mailing Address - Fax:
Practice Address - Street 1:286 MADISON AVENUE
Practice Address - Street 2:SUITE 1602
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017
Practice Address - Country:US
Practice Address - Phone:917-704-3761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0156821103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02567971Medicaid
NYVM5781Medicare UPIN