Healthcare Provider Details

I. General information

NPI: 1558029629
Provider Name (Legal Business Name): JACOB IAN MARGOLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 BROWN PL
BRONX NY
10454-4140
US

IV. Provider business mailing address

590 AVENUE OF AMERICAS
NEW YORK NY
10011-9904
US

V. Phone/Fax

Practice location:
  • Phone: 860-849-9317
  • Fax:
Mailing address:
  • Phone: 860-849-9317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101325
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: