Provider Demographics
NPI:1407152333
Name:JACOB, JUDD (PT, CLS)
Entity Type:Individual
Prefix:
First Name:JUDD
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:PT, CLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-4803
Mailing Address - Country:US
Mailing Address - Phone:914-328-8077
Mailing Address - Fax:914-328-6083
Practice Address - Street 1:340 S BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705-2049
Practice Address - Country:US
Practice Address - Phone:914-968-5125
Practice Address - Fax:914-968-5123
Is Sole Proprietor?:No
Enumeration Date:2011-02-10
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032031225100000X
NY014999247ZC0005X
226448247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400133776Medicare PIN
NYA400133798Medicare PIN
NYA400133789Medicare PIN
NYA400133792Medicare PIN