Provider Demographics
NPI:1659636983
Name:JACOBOWITZ, DERIENNE LYNNE
Entity Type:Individual
Prefix:MS
First Name:DERIENNE
Middle Name:LYNNE
Last Name:JACOBOWITZ
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 1:28 HOMESTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2119
Mailing Address - Country:US
Mailing Address - Phone:646-831-4956
Mailing Address - Fax:
Practice Address - Street 1:358 SAINT MARKS PL
Practice Address - Street 2:4TH FLOOR
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2417
Practice Address - Country:US
Practice Address - Phone:718-727-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program