Provider Demographics
NPI:1821468257
Name:JACOB, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 ANGELA LN
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4626
Mailing Address - Country:US
Mailing Address - Phone:281-781-9578
Mailing Address - Fax:
Practice Address - Street 1:212 ANGELA LN
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477
Practice Address - Country:US
Practice Address - Phone:281-781-9578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126808363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner