Basic Information
| Provider Information | |||||||||
| NPI: | 1871075119 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | DAISY | ||||||||
| MiddleName: | SOBHA | ||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | DAISY | ||||||||
| OtherMiddleName: | SOBHA | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 732973 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732973 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177021215 | ||||||||
| FaxNumber: | 8179276843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2018 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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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 | 163W00000X | 734278 | TX | N | Nursing Service Providers | Registered Nurse | 363L00000X | AP137437 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP137437 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.