Healthcare Provider Details

I. General information

NPI: 1902157761
Provider Name (Legal Business Name): JACOB BORG PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 OFFICE PARK DR
PALM COAST FL
32137-3855
US

IV. Provider business mailing address

4 OFFICE PARK DR
PALM COAST FL
32137-3855
US

V. Phone/Fax

Practice location:
  • Phone: 386-986-7222
  • Fax: 386-401-2414
Mailing address:
  • Phone: 386-986-7222
  • Fax: 386-401-2414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number004633
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY8488
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: