=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912068602
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE P. JACOBUS PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 08/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 STATE ROUTE 28 SUITE 206
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-1979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-534-1233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 MOUNTAIN RD
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08833-5030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-534-1233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3031
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------