Provider Demographics
NPI:1467039982
Name:JAMES, JACOB (LPN)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JAMES
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 1:55 BRITTANY FARMS RD APT 105
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1202
Mailing Address - Country:US
Mailing Address - Phone:860-922-1309
Mailing Address - Fax:
Practice Address - Street 1:511 E COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2506
Practice Address - Country:US
Practice Address - Phone:413-733-3488
Practice Address - Fax:413-732-5856
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20059164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse