Provider Demographics
NPI:1821345737
Name:JACOB, JINCY
Entity Type:Individual
Prefix:
First Name:JINCY
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 1:3110 QUEENS BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3002
Mailing Address - Country:US
Mailing Address - Phone:718-593-4121
Mailing Address - Fax:
Practice Address - Street 1:3110 QUEENS BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3002
Practice Address - Country:US
Practice Address - Phone:718-593-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022573235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist