=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639224959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRANCINE JACOBS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2007
-----------------------------------------------------
Last Update Date | 10/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 82 MIDDLE COUNTRY ROAD ELSIE OWENS NORTH BROOKHAVEN HEALTH CENTER
-----------------------------------------------------
City | CORAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-854-2301
-----------------------------------------------------
Fax | 631-854-2298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26666 PHS PROVIDER ENROLLMENT
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87125-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-923-6770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 227972
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD2010-0581
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------