Healthcare Provider Details

I. General information

NPI: 1447977251
Provider Name (Legal Business Name): JACOB LOGAN WASSERMAN LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 ROUTE 44 STE F
SALT POINT NY
12578-8040
US

IV. Provider business mailing address

10 DUTTON RD APT A210
POUGHKEEPSIE NY
12601-2089
US

V. Phone/Fax

Practice location:
  • Phone: 845-768-3178
  • Fax: 845-622-3636
Mailing address:
  • Phone: 603-969-4696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017772
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: