Basic Information
| Provider Information | |||||||||
| NPI: | 1841332715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | ERIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 STONEWAY LN | ||||||||
| Address2: | |||||||||
| City: | MERION STATION | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190661820 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3905 FORD RD | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191312824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156435400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | PS015808 | PA | X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC2200X | PS015808 | PA | X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.