Provider Demographics
NPI:1023849015
Name:JACOB, ALLEN (PT,DPT)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 MARTIN AVE BLDG SUITE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4325
Mailing Address - Country:US
Mailing Address - Phone:917-525-6773
Mailing Address - Fax:
Practice Address - Street 1:1441 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3779
Practice Address - Country:US
Practice Address - Phone:718-303-9777
Practice Address - Fax:718-303-9778
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist