Basic Information
| Provider Information | |||||||||
| NPI: | 1043759228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | JENSEN | ||||||||
| MiddleName: | KOSHY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 REGINA PL | ||||||||
| Address2: | |||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107031125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144007374 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 GUSTAVE L LEVY PL | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122562904 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2017 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 020643 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.