Provider Demographics
NPI:1962107847
Name:JACKOB, STEPHANIE (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JACKOB
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LARCHMONT DR
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL JUNCTION
Mailing Address - State:NY
Mailing Address - Zip Code:12533-5226
Mailing Address - Country:US
Mailing Address - Phone:914-474-0248
Mailing Address - Fax:
Practice Address - Street 1:488 FREEDOM PLAINS RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-2689
Practice Address - Country:US
Practice Address - Phone:845-452-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311229363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner