Provider Demographics
NPI:1073397717
Name:JACOB, VILNA D
Entity Type:Individual
Prefix:MS
First Name:VILNA
Middle Name:D
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 1:1950 SE PORT ST LUCIE BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5579
Mailing Address - Country:US
Mailing Address - Phone:772-446-4871
Mailing Address - Fax:
Practice Address - Street 1:1950 SE PORT ST LUCIE BLVD STE 212
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5579
Practice Address - Country:US
Practice Address - Phone:772-446-4871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL238668376J00000X
238668376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker