Provider Demographics
NPI:1235586892
Name:JACOB, SHINY (ANP)
Entity Type:Individual
Prefix:
First Name:SHINY
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3043
Mailing Address - Country:US
Mailing Address - Phone:516-784-9477
Mailing Address - Fax:
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:CARDIOLOGY
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:516-632-4260
Practice Address - Fax:516-766-3857
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307619-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health