Provider Demographics
NPI:1831784438
Name:COENE, JACOB ROBERT
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:COENE
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 1:3458 NEELY RD
Mailing Address - Street 2:
Mailing Address - City:JBMDL
Mailing Address - State:NJ
Mailing Address - Zip Code:08641-5312
Mailing Address - Country:US
Mailing Address - Phone:866-377-2778
Mailing Address - Fax:609-754-9249
Practice Address - Street 1:3458 NEELY RD
Practice Address - Street 2:
Practice Address - City:JBMDL
Practice Address - State:NJ
Practice Address - Zip Code:08641-5312
Practice Address - Country:US
Practice Address - Phone:866-377-2778
Practice Address - Fax:609-754-9249
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101276554208D00000X, 208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
040208021620OtherTRICARE