Basic Information
| Provider Information | |||||||||
| NPI: | 1295994853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COGEN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | FRANKLIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 N FRANKLIN BLVD | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | PLEASANTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082322547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092729040 | ||||||||
| FaxNumber: | 6092729055 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 N FRANKLIN BLVD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PLEASANTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082322547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154812725 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2008 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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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 | 207Q00000X | MT189723 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25MA08626400 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0215571 | 05 | NJ | MEDICAID |