MEDICARE: DR. ED 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	101Y00000X	Counselor	650	WV

General Provider Information

NPI Number	:	1831310473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ED JACOBS PHD

Provider Business Mailing Address
First Line	:	457 BROADWAY AVE
Second Line	:
City	:	STAR CITY
State	:	WV
Zip	:	26505
Country	:	US
Telephone Number	:	304-599-0109
Fax Number	:	304-599-6683

Provider Business Practice Location Address
First Line	:	457 BROADWAY AVE
Second Line	:
City	:	STAR CITY
State	:	WV
Zip	:	26505
Country	:	US
Telephone Number	:	304-599-0109
Fax Number	:	304-599-6683

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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