Provider Demographics
NPI:1861865552
Name:KLEIN, JACOB (PA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KLEIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:COBLESKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12043-5071
Mailing Address - Country:US
Mailing Address - Phone:518-231-5091
Mailing Address - Fax:
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:DEPARTMENT OF EMERGENCY & OBSERVATION SERVICES
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534
Practice Address - Country:US
Practice Address - Phone:518-828-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant