Provider Demographics
NPI:1134646631
Name:JACOB, ELISSA LEE
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:LEE
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 1:655 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ABINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18411-8740
Mailing Address - Country:US
Mailing Address - Phone:570-842-9323
Mailing Address - Fax:570-842-9362
Practice Address - Street 1:25 WEST ST
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-1405
Practice Address - Country:US
Practice Address - Phone:570-996-6200
Practice Address - Fax:570-996-6201
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT025019208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGMedicaid