Provider Demographics
NPI:1235447855
Name:JACOB, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
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 1:4175 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7639
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:550 MAMARONECK AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-1634
Practice Address - Country:US
Practice Address - Phone:914-777-3737
Practice Address - Fax:914-777-0914
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0328901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist