1558513663 NPI number — JAIS MATHEW JACOB MSN, RN, FNP-C

Table of content: JAIS MATHEW JACOB MSN, RN, FNP-C (NPI 1558513663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558513663 NPI number — JAIS MATHEW JACOB MSN, RN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOB
Provider First Name:
JAIS
Provider Middle Name:
MATHEW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558513663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4018 CARRINGTON DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-360-1164
Provider Business Mailing Address Fax Number:
972-240-1412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 VALLEY VIEW LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75062-1721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-812-1091
Provider Business Practice Location Address Fax Number:
972-812-1093
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  692194 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 692194 . This is a "TX LICENSES" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com