Basic Information
| Provider Information | |||||||||
| NPI: | 1124050273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | SLOAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | PURCHASE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105772547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146075730 | ||||||||
| FaxNumber: | 2032611970 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | PURCHASE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148488030 | ||||||||
| FaxNumber: | 9148488031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 003284 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 402856 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NY | MEDICAID |