MEDICARE: MS. ANSU JACOB

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	363A00000X	Physician Assistant	MA056682	PA
2	363A00000X	Physician Assistant	028078	NY

General Provider Information

NPI Number	:	1679994529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANSU JACOB

Provider Business Mailing Address
First Line	:	766 SELMER RD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3632
Country	:	US
Telephone Number	:	267-393-3496
Fax Number	:

Provider Business Practice Location Address
First Line	:	1412 FAIRMOUNT AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-2908
Country	:	US
Telephone Number	:	215-235-9600
Fax Number	:

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

Provider Enumeration Date	:	12/19/2013
Last Update Date	:	03/18/2026

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