Provider Demographics
NPI:1093480832
Name:JACOB, LEENU (OD)
Entity Type:Individual
Prefix:
First Name:LEENU
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2204
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:
Practice Address - Street 1:2061 N SQUIRREL RD UNIT 1976
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2350
Practice Address - Country:US
Practice Address - Phone:248-243-3710
Practice Address - Fax:248-282-1756
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist