Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Miss. Stacy Jacob

Individual provider Licensed Practical Nurse · NPI 1104333178

Miss. Stacy Jacob is a Physician Assistant in Staten Island, New York. Qualified in 2022, 4 years ago. Practices with North Shore-Lij Medical PC, a 6,350-clinician group and accepts Medicare assignment. Licensed in New Jersey and New York.

Years since qualifying
4
Licensed in
NJ, NY
In the registry since
2017
Specialties on file
3
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Practice location Address checks out

475 Seaview Ave
Staten Island, NY 10305-3436
Phone: (718) 266-9000
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Physician Assistant (primary) Taxonomy 363A00000X · Licence 25MP00995000 (NJ)
Licensed Practical Nurse Taxonomy 164W00000X · Licence 329541-1 (NY)
Physician Assistant Taxonomy 363A00000X

Record details

NPI number1104333178
Entity typeIndividual (Type 1)
GenderFemale
Sole proprietorNo
NPI enumeratedDecember 29, 2017
Last updated in NPPESFebruary 2, 2026
Certification dateFebruary 2, 2026

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICIAN ASSISTANT
Medical schoolOTHER
Graduated 2022 (4 years in practice)
Group practice North Shore-Lij Medical Pc — 6350 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations5 on file with Medicare

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