Provider Demographics
NPI:1376826503
Name:JACOB, LATHA (NP)
Entity Type:Individual
Prefix:
First Name:LATHA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14131 MIDWAY ROAD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3669
Mailing Address - Country:US
Mailing Address - Phone:972-249-0200
Mailing Address - Fax:972-249-0206
Practice Address - Street 1:14131 MIDWAY ROAD
Practice Address - Street 2:SUITE 620
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3669
Practice Address - Country:US
Practice Address - Phone:972-249-0200
Practice Address - Fax:972-249-0206
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX739362363L00000X, 163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB139648Medicare PIN