Provider Demographics
NPI:1174224711
Name:JACOB, JANELLE N
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:N
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 GARVAN ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3032
Mailing Address - Country:US
Mailing Address - Phone:860-983-0708
Mailing Address - Fax:
Practice Address - Street 1:73 WATERBURY RD UNIT 3
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1252
Practice Address - Country:US
Practice Address - Phone:860-983-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT24-0636246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT20-0579Medicaid
CT92-2397046Medicaid