Healthcare Provider Details

I. General information

NPI: 1053634626
Provider Name (Legal Business Name): GINA T JACOB DOCTORATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DUKE DR
MANHASSET HILLS NY
11040-1207
US

IV. Provider business mailing address

1 DUKE DR
MANHASSET HILLS NY
11040-1207
US

V. Phone/Fax

Practice location:
  • Phone: 516-365-3750
  • Fax:
Mailing address:
  • Phone: 516-365-3750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number053427
License Number StateNY

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: