Provider Demographics
NPI:1376420059
Name:JACOB, ELDHO CHACKO
Entity type:Individual
Prefix:
First Name:ELDHO
Middle Name:CHACKO
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 N BROADWAY APT 624
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-2021
Mailing Address - Country:US
Mailing Address - Phone:929-758-0776
Mailing Address - Fax:
Practice Address - Street 1:377 N BROADWAY APT 624
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-2021
Practice Address - Country:US
Practice Address - Phone:929-758-0776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-16
Last Update Date:2025-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY763250163WP0809X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult