Provider Demographics
NPI:1073032322
Name:JACOB, MINI JOHN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:MINI
Middle Name:JOHN
Last Name:JACOB
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2931
Mailing Address - Country:US
Mailing Address - Phone:516-358-5038
Mailing Address - Fax:
Practice Address - Street 1:705 N 5TH ST
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-2931
Practice Address - Country:US
Practice Address - Phone:516-358-5038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF341923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily