Provider Demographics
NPI:1447748843
Name:THENGAMPALLIL, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:THENGAMPALLIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 OLD ORANGEBURG RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:NY
Mailing Address - Zip Code:10962-1157
Mailing Address - Country:US
Mailing Address - Phone:845-680-8694
Mailing Address - Fax:
Practice Address - Street 1:140 OLD ORANGEBURG RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:NY
Practice Address - Zip Code:10962-1157
Practice Address - Country:US
Practice Address - Phone:845-680-8694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY592600163WP0809X
NY403172363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult