Provider Demographics
NPI:1538571799
Name:JACOB, JERRY (CRNA)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 ROUTE 25A
Mailing Address - Street 2:SUITE 225
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8556
Mailing Address - Country:US
Mailing Address - Phone:631-744-3671
Mailing Address - Fax:631-744-6205
Practice Address - Street 1:333 ROUTE 25A
Practice Address - Street 2:SUITE 225
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-8556
Practice Address - Country:US
Practice Address - Phone:631-744-3671
Practice Address - Fax:631-744-6205
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY573032207L00000X
NY105943367500000X
FLAPRN9384865367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology