Basic Information
| Provider Information | |||||||||
| NPI: | 1699201970 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | BEENA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 E MAIN ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | SMITHTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117872912 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 MINEOLA BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166633511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2017 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F307794-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.