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General NPI Number Information
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NPI Number | 1932816402
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Entity Type | Individual
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Provider Name | MICHAEL JACOBS PHD
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Gender | Male
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Dates
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Enumeration Date | 11/03/2022
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Last Update Date | 11/10/2023
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Provider Practice Location Address
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Address Line | 6800 WISCONSIN AVE
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City | CHEVY CHASE
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State | MD
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Zip | 20815-6105
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Country | US
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Telephone | 917-426-3538
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Fax |
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Provider Business Mailing Address
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Address Line | 11 KRISTY DR
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City | BETHEL
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State | CT
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Zip | 06801-3001
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Country | US
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Telephone | 860-712-0663
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 4481
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 06770
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 025590-01
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License Number State | NY
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