Provider Demographics
NPI:1194990895
Name:JACOB, JESU (DO)
Entity type:Individual
Prefix:DR
First Name:JESU
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-0304
Mailing Address - Country:US
Mailing Address - Phone:631-670-7800
Mailing Address - Fax:631-670-7798
Practice Address - Street 1:66 HARNED RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3527
Practice Address - Country:US
Practice Address - Phone:631-670-7800
Practice Address - Fax:631-670-7798
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235713207X00000X
AL1021207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery