Provider Demographics
NPI:1114367844
Name:JACOBS, TANISHA (LPN)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1483 LINCOLN PL
Mailing Address - Street 2:APT 15
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-4150
Mailing Address - Country:US
Mailing Address - Phone:347-898-4562
Mailing Address - Fax:
Practice Address - Street 1:295 FLATBUSH AVENUE EXT
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3001
Practice Address - Country:US
Practice Address - Phone:718-522-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281812164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse