Provider Demographics
NPI:1255412946
Name:JACUBOWITZ, TOMASITA RIVERA (NP)
Entity type:Individual
Prefix:MISS
First Name:TOMASITA
Middle Name:RIVERA
Last Name:JACUBOWITZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4522
Mailing Address - Country:US
Mailing Address - Phone:336-621-2500
Mailing Address - Fax:336-478-2541
Practice Address - Street 1:2500 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-4522
Practice Address - Country:US
Practice Address - Phone:336-621-2500
Practice Address - Fax:336-478-2541
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC600034363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004004Medicaid
NCP57476Medicare UPIN
NC7004004Medicaid