Basic Information
| Provider Information | |||||||||
| NPI: | 1063488799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 ROCKAWAY TPKE | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115591216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163745024 | ||||||||
| FaxNumber: | 5163745816 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 ROCKAWAY TPKE | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115591216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163745024 | ||||||||
| FaxNumber: | 5163745816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363AM0700X | 007220 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2153542 | 05 | NY | MEDICAID |