Healthcare Provider Details

I. General information

NPI: 1326659012
Provider Name (Legal Business Name): JACOB ADRIAN LAFO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 11/30/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST STE 430
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

450 VETERANS MEMORIAL PKWY STE 8B
EAST PROVIDENCE RI
02914-5315
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4500
  • Fax: 401-444-6643
Mailing address:
  • Phone: 401-529-4884
  • Fax: 401-519-6619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01845
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: