Basic Information
| Provider Information | |||||||||
| NPI: | 1518290139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBUS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIDSON | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | KATHERINE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 81 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019702714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787411200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 750 BRUNSWICK AVE | ||||||||
| Address2: | FULD CAMPUS, CVIR DEPARTMENT | ||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086384143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093946000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2009 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 25MP00224300 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA053987 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA5922 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.