=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831567981
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPHANIE JACOBS, PHD, LMHC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2015
-----------------------------------------------------
Last Update Date | 09/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 W 30TH ST 2F
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-439-0628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 W 30TH ST 2F
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHANIE JACOBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-439-0628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 004724
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------