Provider Demographics
NPI:1538522487
Name:JACOBS, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 RXR PLZ FL 13
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-453-0435
Mailing Address - Fax:646-846-3283
Practice Address - Street 1:5600 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-1017
Practice Address - Country:US
Practice Address - Phone:631-563-7828
Practice Address - Fax:631-563-7837
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine