Provider Demographics
NPI:1659109643
Name:JACOBY, KIM MOON JA (RN, BS)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MOON JA
Last Name:JACOBY
Suffix:
Gender:F
Credentials:RN, BS
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MOON JA
Other - Last Name:JACOBY HORNLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BS
Mailing Address - Street 1:800 MACBEAN LN
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-9310
Mailing Address - Country:US
Mailing Address - Phone:914-433-3338
Mailing Address - Fax:
Practice Address - Street 1:6 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1257
Practice Address - Country:US
Practice Address - Phone:914-433-3338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY467366-01163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)Group - Single Specialty