Provider Demographics
NPI:1568930113
Name:JACOB, BEENA
Entity Type:Individual
Prefix:
First Name:BEENA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 FINISH LINE RD
Mailing Address - Street 2:
Mailing Address - City:BAHAMA
Mailing Address - State:NC
Mailing Address - Zip Code:27503-9657
Mailing Address - Country:US
Mailing Address - Phone:919-479-6785
Mailing Address - Fax:
Practice Address - Street 1:4505 FAIR MEADOWS LN STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6449
Practice Address - Country:US
Practice Address - Phone:919-787-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011196363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner