Provider Demographics
NPI:1043635899
Name:JACOB, RIYA
Entity Type:Individual
Prefix:
First Name:RIYA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:
Practice Address - Street 1:1150 N 35TH AVENUE
Practice Address - Street 2:SUITE 605
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-443-3542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9274670363L00000X
FL9274670363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner