Basic Information
| Provider Information | |||||||||
| NPI: | 1285898684 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | JEENA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 BERGEN STREET | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739725128 | ||||||||
| FaxNumber: | 9739726646 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 BERGEN STREET | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739725128 | ||||||||
| FaxNumber: | 9739726646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 49154 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64302083 | 05 | CO | MEDICAID | 022167 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER |