Provider Demographics
NPI:1255695003
Name:JACOB, JENNIE Z (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:Z
Last Name:JACOB
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 GEHRIG ST
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3487
Practice Address - Country:US
Practice Address - Phone:631-444-6270
Practice Address - Fax:631-444-7620
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant