Provider Demographics
NPI:1922330513
Name:JACOB, BETTY
Entity Type:Individual
Prefix:
First Name:BETTY
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 1:251 E 86TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-3115
Mailing Address - Country:US
Mailing Address - Phone:212-427-6940
Mailing Address - Fax:212-831-5694
Practice Address - Street 1:251 E 86TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-3115
Practice Address - Country:US
Practice Address - Phone:212-427-6940
Practice Address - Fax:212-831-5694
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053658-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist