Provider Demographics
NPI:1861821969
Name:ZUKOSKI, JACOB ALLEN
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:ALLEN
Last Name:ZUKOSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CAVE HOLW
Mailing Address - Street 2:
Mailing Address - City:WEST HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14586-9568
Mailing Address - Country:US
Mailing Address - Phone:585-683-4826
Mailing Address - Fax:
Practice Address - Street 1:75 CAVE HOLW
Practice Address - Street 2:
Practice Address - City:WEST HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14586-9568
Practice Address - Country:US
Practice Address - Phone:585-683-4826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316988-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse