Provider Demographics
NPI:1902157761
Name:BORG, JACOB (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:BORG
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 1:2 PINE LAKES PARKWAY NORTH
Mailing Address - Street 2:SUITE NUMBER 6
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137
Mailing Address - Country:US
Mailing Address - Phone:386-447-4145
Mailing Address - Fax:386-447-2827
Practice Address - Street 1:2 PINE LAKES PKWY N
Practice Address - Street 2:SUITE NUMBER 6
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3643
Practice Address - Country:US
Practice Address - Phone:386-447-4145
Practice Address - Fax:386-447-2827
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8488103T00000X
NY004633103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist