Healthcare Provider Details

I. General information

NPI: 1619671310
Provider Name (Legal Business Name): JACOB NATHANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 WASHINGTON ST
BRIGHTON MA
02135-3376
US

IV. Provider business mailing address

2225 E EVESHAM RD STE 101
VOORHEES NJ
08043-1557
US

V. Phone/Fax

Practice location:
  • Phone: 857-392-3598
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1026954
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: