Healthcare Provider Details

I. General information

NPI: 1497799076
Provider Name (Legal Business Name): DOUGLAS GEORGE JACOBS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/27/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PROFESSIONAL PSYCHIATRIC ASSOC 33 LILLIAN WAY
WAYLAND MA
01778
US

IV. Provider business mailing address

PROFESSIONAL PSYCHIATRIC ASSOC 33 LILLIAN WAY
WAYLAND MA
01778
US

V. Phone/Fax

Practice location:
  • Phone: 781-591-5221
  • Fax: 781-235-6390
Mailing address:
  • Phone: 781-591-5221
  • Fax: 781-235-6390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34367
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: