Provider Demographics
NPI:1457630899
Name:JESU JACOB, D.O., P.C.
Entity Type:Organization
Organization Name:JESU JACOB, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:JESU
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-670-7800
Mailing Address - Street 1:66 HARNED RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3527
Mailing Address - Country:US
Mailing Address - Phone:631-670-7800
Mailing Address - Fax:631-670-7798
Practice Address - Street 1:66 HARNED RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3527
Practice Address - Country:US
Practice Address - Phone:631-670-7800
Practice Address - Fax:631-670-7798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235713207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty