Basic Information
Provider Information | |||||||||
NPI: | 1912293184 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOB | ||||||||
FirstName: | CIMY | ||||||||
MiddleName: | SUSAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | UPMC CHILDRENS SPECIALIST- NEUROLOGY | ||||||||
Address2: | 3 WALNUT STREET, SUITE 205 | ||||||||
City: | LEMOYNE | ||||||||
State: | PA | ||||||||
PostalCode: | 170431168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7179880090 | ||||||||
FaxNumber: | 7172215320 | ||||||||
Practice Location | |||||||||
Address1: | UPMC CHILDRENS SPECIALIST- NEUROLOGY | ||||||||
Address2: | 3 WALNUT STREET, SUITE 205 | ||||||||
City: | LEMOYNE | ||||||||
State: | PA | ||||||||
PostalCode: | 170431168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7179880090 | ||||||||
FaxNumber: | 7172215320 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2011 | ||||||||
LastUpdateDate: | 10/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | MD475318 | PA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | C1-0010960 | DE | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
No ID Information.