Provider Demographics
NPI:1073863023
Name:JACOB, MARIAMMA M (CPNP)
Entity Type:Individual
Prefix:
First Name:MARIAMMA
Middle Name:M
Last Name:JACOB
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:MARIAMMA
Other - Middle Name:M
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7800 PRESTON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3236
Mailing Address - Country:US
Mailing Address - Phone:972-608-3800
Mailing Address - Fax:972-608-3810
Practice Address - Street 1:7800 PRESTON RD STE 300
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3236
Practice Address - Country:US
Practice Address - Phone:972-608-3800
Practice Address - Fax:972-608-3810
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX557515363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics