Provider Demographics
NPI:1104371020
Name:JACOB, PRAISY (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:PRAISY
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:PRAISY
Other - Middle Name:
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50861 NESTING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1385
Mailing Address - Country:US
Mailing Address - Phone:586-764-9892
Mailing Address - Fax:
Practice Address - Street 1:50861 NESTING RIDGE DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1385
Practice Address - Country:US
Practice Address - Phone:586-764-9892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704281141363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily