Provider Demographics
NPI:1790566842
Name:JACOBS, KHISHIGZAYA
Entity Type:Individual
Prefix:
First Name:KHISHIGZAYA
Middle Name:
Last Name:JACOBS
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 1:7210 37TH AVE APT 222
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6202
Mailing Address - Country:US
Mailing Address - Phone:702-862-6848
Mailing Address - Fax:
Practice Address - Street 1:7210 37TH AVE APT 222
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6202
Practice Address - Country:US
Practice Address - Phone:702-862-6848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist