MEDICARE: ALEXANDRA D. JACOBUS LCSW

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	1041C0700X	Clinical Social Worker	071630	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P2739151	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1578635769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA D. JACOBUS LCSW

Provider Business Mailing Address
First Line	:	360 9TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-4008
Country	:	US
Telephone Number	:	718-768-6839
Fax Number	:	718-768-0998

Provider Business Practice Location Address
First Line	:	360 9TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-4008
Country	:	US
Telephone Number	:	718-768-6839
Fax Number	:	718-768-0998

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	07/08/2007

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