Healthcare Provider Details

I. General information

NPI: 1932306446
Provider Name (Legal Business Name): PERSONAL IMAGE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 KINDERKAMACK RD SUITE 205
ORADELL NJ
07649-1600
US

IV. Provider business mailing address

PO BOX 98
HILLSDALE NJ
07642-0098
US

V. Phone/Fax

Practice location:
  • Phone: 201-969-9900
  • Fax:
Mailing address:
  • Phone: 201-969-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number25MB06930400
License Number StateNJ

VIII. Authorized Official

Name: JEFFRY L JACOBS
Title or Position: PRESIDENT
Credential: D.O., FACOS
Phone: 201-969-9900