Provider Demographics
NPI:1174413934
Name:JACOB, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WALLACE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-2926
Mailing Address - Country:US
Mailing Address - Phone:516-641-0245
Mailing Address - Fax:
Practice Address - Street 1:6851 JERICHO TPKE STE 125
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4454
Practice Address - Country:US
Practice Address - Phone:516-780-0111
Practice Address - Fax:516-441-1099
Is Sole Proprietor?:No
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program