Healthcare Provider Details

I. General information

NPI: 1750214698
Provider Name (Legal Business Name): CHARLES JACOBSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W VIRGINIA AVE
JACKSON NJ
08527-2124
US

IV. Provider business mailing address

25 W VIRGINIA AVE
JACKSON NJ
08527-2124
US

V. Phone/Fax

Practice location:
  • Phone: 347-831-3136
  • Fax:
Mailing address:
  • Phone: 347-831-3136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06392100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: