MEDICARE: DR. MINDY RUTH JACOBS PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY1011	DC

General Provider Information

NPI Number	:	1598252660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MINDY RUTH JACOBS PHD

Provider Business Mailing Address
First Line	:	1808 T ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-7126
Country	:	US
Telephone Number	:	202-236-6365
Fax Number	:

Provider Business Practice Location Address
First Line	:	1808 T ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-7126
Country	:	US
Telephone Number	:	202-236-6365
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2018
Last Update Date	:	04/15/2018

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