Provider Demographics
NPI:1568084507
Name:NASSER, JACOB (DPM)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:NASSER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 BEACH 19TH ST # 11691
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4423
Mailing Address - Country:US
Mailing Address - Phone:917-595-0822
Mailing Address - Fax:
Practice Address - Street 1:327 BEACH 19TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4423
Practice Address - Country:US
Practice Address - Phone:917-595-0822
Practice Address - Fax:203-384-4598
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
NYP122264390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP122264Medicaid