Provider Demographics
NPI:1720306350
Name:JACOB, RAIMOL (NP)
Entity type:Individual
Prefix:MS
First Name:RAIMOL
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:61 MANORHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1627
Mailing Address - Country:US
Mailing Address - Phone:516-883-7100
Mailing Address - Fax:516-883-7474
Practice Address - Street 1:2488 GRAND CONCOURSE
Practice Address - Street 2:4TH FLOOR ROOM 424
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5203
Practice Address - Country:US
Practice Address - Phone:212-695-5122
Practice Address - Fax:516-484-6084
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF335357363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily