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General NPI Number Information
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NPI Number | 1205645454
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Entity Type | Individual
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Provider Name | STEPHANIE JACOB
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Gender | Female
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Dates
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Enumeration Date | 01/02/2025
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Last Update Date | 01/02/2025
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Provider Practice Location Address
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Address Line | 109 2ND ST UNIT 1
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City | HOBOKEN
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State | NJ
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Zip | 07030-7789
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Country | US
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Telephone | 201-420-0644
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Fax |
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Provider Business Mailing Address
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Address Line | 201 RAILROAD AVE APT 205
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City | EAST RUTHERFORD
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State | NJ
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Zip | 07073-1945
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Country | US
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Telephone | 201-724-3129
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 27OA00733700
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License Number State | NJ
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