Provider Demographics
NPI:1144855818
Name:PERRY, JACOB FORD
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:FORD
Last Name:PERRY
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 1:720 FT WASHINGTON AVE APT 4T
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-3725
Mailing Address - Country:US
Mailing Address - Phone:917-699-7954
Mailing Address - Fax:
Practice Address - Street 1:1430 BROADWAY RM 1510
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-3368
Practice Address - Country:US
Practice Address - Phone:212-262-2850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026576103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist