Provider Demographics
NPI:1891452959
Name:JACOB, ANISHA SARA (NP)
Entity type:Individual
Prefix:MRS
First Name:ANISHA
Middle Name:SARA
Last Name:JACOB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:ANISHA
Other - Middle Name:SARA
Other - Last Name:CHACKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18 SEITZ DR
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-6017
Mailing Address - Country:US
Mailing Address - Phone:516-355-8757
Mailing Address - Fax:
Practice Address - Street 1:18 SEITZ DR
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-6017
Practice Address - Country:US
Practice Address - Phone:516-355-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY347205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily