=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467675819
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN VIVIAN JACOB PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 VANDERVENTER AVE
-----------------------------------------------------
City | PORT WASHINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11050-3737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-944-3786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 VANDERVENTER AVE
-----------------------------------------------------
City | PORT WASHINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11050-3737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-944-3786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 0077981
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------