Provider Demographics
NPI:1740793371
Name:JACOB, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
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 1:924 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-3986
Mailing Address - Country:US
Mailing Address - Phone:973-932-7401
Mailing Address - Fax:
Practice Address - Street 1:924 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-3986
Practice Address - Country:US
Practice Address - Phone:973-932-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00536800363AM0700X
IL085007899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty