Individual
DR. SUSAN VIVIAN JACOB
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
14 VANDERVENTER AVE, PORT WASHINGTON, NY 11050-3737
(516) 944-3786
Mailing address
14 VANDERVENTER AVE, PORT WASHINGTON, NY 11050-3737
(516) 944-3786
Taxonomy
Speciality
Code
Description
License number
State
103TC2200X
Clinical Child & Adolescent Psychologist
Primary
0077981
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0077981
LICENSE NUMBER
NY
Enumeration date
04/11/2007
Last updated
07/08/2007
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