Provider Demographics
NPI:1114588001
Name:COBBS, JEFFERY (LPN, RRT)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:COBBS
Suffix:
Gender:M
Credentials:LPN, RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12734-0475
Mailing Address - Country:US
Mailing Address - Phone:845-292-0489
Mailing Address - Fax:
Practice Address - Street 1:81 DWYER AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-1524
Practice Address - Country:US
Practice Address - Phone:845-428-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0102802279G1100X
NY308060164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No2279G1100XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredGeneral Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY308060OtherLPN LICENSE NUMBER