Provider Demographics
NPI:1831801844
Name:JACOBS, FRED HENRY
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:HENRY
Last Name:JACOBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 BARBADOS DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-3002
Mailing Address - Country:US
Mailing Address - Phone:856-278-1904
Mailing Address - Fax:
Practice Address - Street 1:493 BEVERLY RANCOCAS RD
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-3517
Practice Address - Country:US
Practice Address - Phone:609-543-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00907900101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor