Healthcare Provider Details

I. General information

NPI: 1437957701
Provider Name (Legal Business Name): JISHA JACOB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 MAIN AVE # 7055
PASSAIC NJ
07055-5066
US

IV. Provider business mailing address

47 OLD MIDDLETOWN RD
NANUET NY
10954-3208
US

V. Phone/Fax

Practice location:
  • Phone: 800-200-8196
  • Fax:
Mailing address:
  • Phone: 708-296-9823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number357923
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number209030880
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15521400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: