Provider Demographics
NPI:1760949994
Name:JACOB, LINO
Entity Type:Individual
Prefix:
First Name:LINO
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 1:1600 ELGIN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2813
Mailing Address - Country:US
Mailing Address - Phone:516-605-5818
Mailing Address - Fax:
Practice Address - Street 1:1600 ELGIN AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2813
Practice Address - Country:US
Practice Address - Phone:516-605-5818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342528363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily