Provider Demographics
NPI:1063033835
Name:SALEM, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SALEM
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 1:220 SOUTH AVE APT 309
Mailing Address - Street 2:
Mailing Address - City:FANWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07023-1213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1418
Practice Address - Country:US
Practice Address - Phone:908-233-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RW03864300183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician