Provider Demographics
NPI:1124050273
Name:JACOBY, SUSAN SLOAN (APRN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:SLOAN
Last Name:JACOBY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2547
Mailing Address - Country:US
Mailing Address - Phone:914-607-5730
Mailing Address - Fax:203-261-1970
Practice Address - Street 1:3030 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577
Practice Address - Country:US
Practice Address - Phone:914-848-8030
Practice Address - Fax:914-848-8031
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003284363LP0808X
NY402856363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid