Provider Demographics
NPI:1518425982
Name:JACOB, MARY DEENA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DEENA
Last Name:JACOB
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109,BURNET DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002
Mailing Address - Country:US
Mailing Address - Phone:214-901-5454
Mailing Address - Fax:
Practice Address - Street 1:411 E MCDERMOTT DR STE A
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-2854
Practice Address - Country:US
Practice Address - Phone:972-227-3464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138925363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily