Provider Demographics
NPI:1144643859
Name:JACOBS, MICHAEL SR
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:JACOBS
Suffix:SR
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 1:351 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1627
Mailing Address - Country:US
Mailing Address - Phone:516-459-8365
Mailing Address - Fax:
Practice Address - Street 1:351 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-1627
Practice Address - Country:US
Practice Address - Phone:516-459-8365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor