Provider Demographics
NPI:1578095634
Name:WEST HAVEN PEDIATRICS, LLC
Entity Type:Organization
Organization Name:WEST HAVEN PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOBEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-932-3227
Mailing Address - Street 1:367 ELM ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4217
Mailing Address - Country:US
Mailing Address - Phone:203-932-3227
Mailing Address - Fax:
Practice Address - Street 1:367 ELM ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4217
Practice Address - Country:US
Practice Address - Phone:203-932-3227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049082261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008061680Medicaid
CT008035471Medicaid