Provider Demographics
NPI:1235487240
Name:JACOB, KATHERINE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GENE DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-5733
Mailing Address - Country:US
Mailing Address - Phone:203-927-6369
Mailing Address - Fax:
Practice Address - Street 1:10 GENE DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-5733
Practice Address - Country:US
Practice Address - Phone:203-927-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-22
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0012428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist