Basic Information
| Provider Information | |||||||||
| NPI: | 1720306350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | RAIMOL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 MANORHAVEN BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110501627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168837100 | ||||||||
| FaxNumber: | 5168837474 | ||||||||
| Practice Location | |||||||||
| Address1: | 2488 GRAND CONCOURSE | ||||||||
| Address2: | 4TH FLOOR ROOM 424 | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104585203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126955122 | ||||||||
| FaxNumber: | 5164846084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 05/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F335357 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.