Provider Demographics
NPI:1356458889
Name:JACOB, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
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:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601
Mailing Address - Country:US
Mailing Address - Phone:412-561-7246
Mailing Address - Fax:412-235-4011
Practice Address - Street 1:1275 SOUTH MAIN STREET
Practice Address - Street 2:SUITE103
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601
Practice Address - Country:US
Practice Address - Phone:412-561-7246
Practice Address - Fax:412-235-4011
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP004352B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAVP004352BOtherLICENSE