Provider Demographics
NPI:1497116255
Name:JACOB, ALEYAMMA (FNP)
Entity Type:Individual
Prefix:
First Name:ALEYAMMA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ALEYAMMA
Other - Middle Name:
Other - Last Name:CHACKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:610 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4105
Mailing Address - Country:US
Mailing Address - Phone:413-447-2684
Mailing Address - Fax:413-445-9197
Practice Address - Street 1:610 NORTH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4105
Practice Address - Country:US
Practice Address - Phone:413-447-2684
Practice Address - Fax:413-445-9197
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN247194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily