Provider Demographics
NPI:1225000581
Name:JACOBS, ALYSHA
Entity Type:Individual
Prefix:
First Name:ALYSHA
Middle Name:
Last Name:JACOBS
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 1:171 W 73RD ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2947
Mailing Address - Country:US
Mailing Address - Phone:917-445-9566
Mailing Address - Fax:516-307-3396
Practice Address - Street 1:2713 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-3591
Practice Address - Country:US
Practice Address - Phone:917-445-9566
Practice Address - Fax:516-307-3396
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01984087Medicaid
NYU76584Medicare UPIN
NY04768Medicare ID - Type Unspecified
NYC58782Medicare ID - Type Unspecified
NY4785420001Medicare NSC