Provider Demographics
NPI:1295573525
Name:MOAK, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MOAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 RIVERVIEW DR STE 325
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-1180
Mailing Address - Country:US
Mailing Address - Phone:973-307-0705
Mailing Address - Fax:
Practice Address - Street 1:999 RIVERVIEW DR STE 325
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-1180
Practice Address - Country:US
Practice Address - Phone:973-307-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-24-73149103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst