Kim Moon Ja Jacoby, RN, BS

Primary specialty

Addiction (Substance Use Disorder) Registered NurseTaxonomy code 163WA0400X

License

467366-01 Issued in NY

Practice address

6 Euclid Ave
Cortland, NY 13045-1257

Phone

(914) 433-3338

NPI assigned

Jul 23, 2024

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Kim Moon Ja Jacoby Hornlein Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Bachelor of Science, Registered Nurse

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1721692800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1723075200000",
    "number": "1659109643",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "800 MACBEAN LN",
            "city": "CORTLAND",
            "state": "NY",
            "postal_code": "130459310",
            "telephone_number": "914-433-3338"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6 EUCLID AVE",
            "city": "CORTLAND",
            "state": "NY",
            "postal_code": "130451257",
            "telephone_number": "914-433-3338"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "334 W State St",
            "address_purpose": "LOCATION",
            "city": "Ithaca",
            "state": "NY",
            "postal_code": "148505432",
            "country_code": "US",
            "telephone_number": "607-273-5500",
            "fax_number": "607-273-1277",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACOBY",
        "first_name": "KIM",
        "middle_name": "MOON JA",
        "credential": "RN, BS",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-07-23",
        "last_updated": "2024-08-08",
        "certification_date": "2024-08-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163WA0400X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, Addiction (Substance Use Disorder)",
            "state": "NY",
            "license": "467366-01",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KIM",
            "last_name": "JACOBY HORNLEIN",
            "middle_name": "MOON JA",
            "credential": "RN, BS",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Addiction (Substance Use Disorder) Registered Nurse in Cortland, NY
• Providers in Cortland, NY by specialty
• Addiction (Substance Use Disorder) Registered Nurse in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.