Provider Demographics
NPI:1982383295
Name:GOTHAM, JACOB J
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:GOTHAM
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 1:1003 PARK ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3911
Mailing Address - Country:US
Mailing Address - Phone:315-713-9090
Mailing Address - Fax:315-713-9330
Practice Address - Street 1:1003 PARK ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-3911
Practice Address - Country:US
Practice Address - Phone:315-713-9090
Practice Address - Fax:315-713-9330
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator