Basic Information
| Provider Information | |||||||||
| NPI: | 1104265180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLEAN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 W 20TH STREET | ||||||||
| Address2: | |||||||||
| City: | RIVIERA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612291659 | ||||||||
| FaxNumber: | 5613312715 | ||||||||
| Practice Location | |||||||||
| Address1: | 7031 SW 62ND AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331434701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052847500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2013 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | UO3093 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.