Healthcare Provider Details

I. General information

NPI: 1437513363
Provider Name (Legal Business Name): JISHA RACHEL JACOB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 08/09/2025
Certification Date: 08/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 LYONS AVE FL 1
NEWARK NJ
07112-2016
US

IV. Provider business mailing address

1400 PELHAM PKWY S
BRONX NY
10461-1138
US

V. Phone/Fax

Practice location:
  • Phone: 973-926-7428
  • Fax:
Mailing address:
  • Phone: 718-918-6981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number299130
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: