=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487478087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE LYNN JAKOBOWSKI AGNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2024
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 CHESTNUT ST FL 16
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-3612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-6760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2406 CORAL ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-285-3250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | SP030978
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------