Provider Demographics
NPI:1477637478
Name:JACOB, JERYL-LYNNE (DC)
Entity Type:Individual
Prefix:DR
First Name:JERYL-LYNNE
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:JERYLYN
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:21 2ND ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2203
Mailing Address - Country:US
Mailing Address - Phone:719-987-0735
Mailing Address - Fax:719-979-4669
Practice Address - Street 1:21 2ND ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2203
Practice Address - Country:US
Practice Address - Phone:719-987-0735
Practice Address - Fax:719-979-4669
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2964111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX1849-1Medicare UPIN