MEDICARE: MS. STETHANIE ANN JACOBS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	012150-1	NY

General Provider Information

NPI Number	:	1124208095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STETHANIE ANN JACOBS PA-C

Provider Business Mailing Address
First Line	:	488 MIDWOOD ST
Second Line	:	APT. 6M
City	:	BROOKLYN
State	:	NY
Zip	:	11225-4517
Country	:	US
Telephone Number	:	908-851-8691
Fax Number	:

Provider Business Practice Location Address
First Line	:	488 MIDWOOD ST
Second Line	:	APT. 6M
City	:	BROOKLYN
State	:	NY
Zip	:	11225-4517
Country	:	US
Telephone Number	:	908-851-8691
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2007
Last Update Date	:	11/08/2007

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