Provider Demographics
NPI:1306922927
Name:JACOB, ZEENA (CRNA)
Entity type:Individual
Prefix:MRS
First Name:ZEENA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:ZEENA
Other - Middle Name:
Other - Last Name:VARUGHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-3326
Mailing Address - Fax:215-707-8028
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-707-3326
Practice Address - Fax:215-707-8028
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY525412-1367500000X
PARN647780367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN647780OtherRN647780
NYA400004907Medicare PIN
NYR3C681Medicare ID - Type Unspecified