Provider Demographics
NPI:1073045456
Name:JACOB, JOBY
Entity Type:Individual
Prefix:
First Name:JOBY
Middle Name:
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 1:330 BROOKLINE AVE
Mailing Address - Street 2:W/SPAN 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-754-4677
Mailing Address - Fax:617-632-0215
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:W/SPAN 2
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-754-4677
Practice Address - Fax:617-632-0215
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAT288042207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine