MEDICARE: JACOB ETHAN SMALL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	0156821	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528087855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB ETHAN SMALL PH.D.

Provider Business Mailing Address
First Line	:	286 MADISON AVENUE
Second Line	:	SUITE 1602
City	:	NEW YORK
State	:	NY
Zip	:	10017
Country	:	US
Telephone Number	:	917-704-3761
Fax Number	:

Provider Business Practice Location Address
First Line	:	286 MADISON AVENUE
Second Line	:	SUITE 1602
City	:	NEW YORK
State	:	NY
Zip	:	10017
Country	:	US
Telephone Number	:	917-704-3761
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	04/29/2008

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