MEDICARE: HEATHER HULALI JACOB FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APRN.CNP.0029555	OH

General Provider Information

NPI Number	:	1295402030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER HULALI JACOB FNP-C

Provider Business Mailing Address
First Line	:	2940 E OVERLOOK RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-2434
Country	:	US
Telephone Number	:	602-284-1702
Fax Number	:

Provider Business Practice Location Address
First Line	:	8655 MARKET ST
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-4112
Country	:	US
Telephone Number	:	440-255-6400
Fax Number	:	440-255-3637

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2021
Last Update Date	:	11/29/2021

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