Provider Demographics
NPI:1376146779
Name:SICINSKI, JACOB (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:SICINSKI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 BATTERY BLVD APT 202
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-4758
Mailing Address - Country:US
Mailing Address - Phone:815-651-0167
Mailing Address - Fax:
Practice Address - Street 1:13000 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-8340
Practice Address - Country:US
Practice Address - Phone:757-269-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202215778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist