Healthcare Provider Details

I. General information

NPI: 1922660844
Provider Name (Legal Business Name): VANESSA SITARA B JACOB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GREEN HOLLOW RD
DANIELSON CT
06239-3509
US

IV. Provider business mailing address

320 POMFRET ST
PUTNAM CT
06260-1836
US

V. Phone/Fax

Practice location:
  • Phone: 860-779-1865
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number69802
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number69802
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: