Healthcare Provider Details

I. General information

NPI: 1972183846
Provider Name (Legal Business Name): JACOB D BLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OLGETOWN STATON RD
NEWARK DE
19718-0001
US

IV. Provider business mailing address

4755 OLGETOWN STATON RD
NEWARK DE
19718-0001
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-1043
  • Fax:
Mailing address:
  • Phone: 302-733-1043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2025044588
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: