Provider Demographics
NPI:1780876045
Name:JACOBS, LAURA (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-5532
Mailing Address - Country:US
Mailing Address - Phone:518-587-1141
Mailing Address - Fax:518-587-1152
Practice Address - Street 1:454 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5532
Practice Address - Country:US
Practice Address - Phone:518-587-1141
Practice Address - Fax:518-587-1152
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0130363AM0700X
NY002791363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400077824Medicare PIN
NYJ400077823Medicare PIN