MEDICARE: JACOB GELLES PSYD

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	015618	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PS1511	OTHER	ME	MAINE PSYCHOLOGIST LICENSE
2	015618	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1770643553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB GELLES PSYD

Provider Business Mailing Address
First Line	:	257 SOUTH ST
Second Line	:
City	:	BIDDEFORD
State	:	ME
Zip	:	04005-2154
Country	:	US
Telephone Number	:	917-225-0383
Fax Number	:

Provider Business Practice Location Address
First Line	:	811 FOSTER AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11230-1358
Country	:	US
Telephone Number	:	917-225-0383
Fax Number	:

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	10/16/2024

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