| Doctor Name: | MARYANN PRAKASH JACOB |
| NPI Number: | 1649665670 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | M.D. |
| License Number: | 94698 |
| Business Practice Address: | 2799 W Grand Blvd Detroit, MI - 482022608 |
| Business Phone Number: | 3138745378 |
| Business Fax Number: | |
| Mailing Address: | 85 Winthrop Ave, YONKERS |
| State: | NY |
| Postal Code: | 107103620 |
| Phone Number: | 9143385455 |
| Fax Number: | |
| NPI Enumeration Date: | 04/06/2015 |
| NPI Last Update Date: | 04/06/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 94698 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ZZ |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |