Provider Demographics
NPI:1407545239
Name:RATLIFF, JACOB M (LPN)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:M
Last Name:RATLIFF
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 PHALEN DR APT A
Mailing Address - Street 2:
Mailing Address - City:COPENHAGEN
Mailing Address - State:NY
Mailing Address - Zip Code:13626-3116
Mailing Address - Country:US
Mailing Address - Phone:315-886-4692
Mailing Address - Fax:
Practice Address - Street 1:714 PHALEN DR APT A
Practice Address - Street 2:
Practice Address - City:COPENHAGEN
Practice Address - State:NY
Practice Address - Zip Code:13626-3116
Practice Address - Country:US
Practice Address - Phone:315-886-4692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344965164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse