Provider Demographics
NPI:1568685436
Name:JACOB, SUSAN (NP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W 168TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-2699
Mailing Address - Country:US
Mailing Address - Phone:212-305-2500
Mailing Address - Fax:
Practice Address - Street 1:710 W 168TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-2699
Practice Address - Country:US
Practice Address - Phone:212-305-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334236363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner