Provider Demographics
NPI:1912562448
Name:JACOBS, IAN TERRELL (LPN)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:TERRELL
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GRANADA CRES APT 19
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-1237
Mailing Address - Country:US
Mailing Address - Phone:718-431-5167
Mailing Address - Fax:
Practice Address - Street 1:4 GRANADA CRES APT 19
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-1237
Practice Address - Country:US
Practice Address - Phone:718-431-5167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324906164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse