Provider Demographics
NPI:1790151215
Name:JACOBY, SAMANTHA ELIZABETH
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:JACOBY
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 1:21 CAROLYN CT
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-4231
Mailing Address - Country:US
Mailing Address - Phone:631-741-8511
Mailing Address - Fax:
Practice Address - Street 1:21 CAROLYN CT
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-4231
Practice Address - Country:US
Practice Address - Phone:631-741-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program