Provider Demographics
NPI:1154619500
Name:JACOBSON, NINA STELLA (MD)
Entity type:Individual
Prefix:DR
First Name:NINA
Middle Name:STELLA
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NINA
Other - Middle Name:STELLA
Other - Last Name:MIZRAHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:19 DAVIS AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-4488
Mailing Address - Country:US
Mailing Address - Phone:732-776-3797
Mailing Address - Fax:732-776-3796
Practice Address - Street 1:19 DAVIS AVE FL 7
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4488
Practice Address - Country:US
Practice Address - Phone:732-776-3797
Practice Address - Fax:732-776-3796
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09482800207V00000X, 207VF0040X, 207VF0040X
NY274143207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010190500Medicaid