Healthcare Provider Details

I. General information

NPI: 1215453857
Provider Name (Legal Business Name): MARIANNE JACOB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 10/06/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 MOUNT PLEASANT AVE
WEST ORANGE NJ
07052-2750
US

IV. Provider business mailing address

48 SYCAMORE LN
ROSLYN HEIGHTS NY
11577-2522
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-6900
  • Fax: 973-322-6999
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number25MB11494800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number297526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: