Healthcare Provider Details

I. General information

NPI: 1205754934
Provider Name (Legal Business Name): JACOB FIEDLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

100 WOODS RD
VALHALLA NY
10595-1530
US

IV. Provider business mailing address

321 E 66TH ST APT 2E
NEW YORK NY
10065-6224
US

V. Phone/Fax

Practice location:
  • Phone: 203-985-5021
  • Fax:
Mailing address:
  • Phone: 203-985-5021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: