Provider Demographics
NPI:1255479556
Name:JACOB, LEENA MARY
Entity Type:Individual
Prefix:
First Name:LEENA
Middle Name:MARY
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 1:14101 PARAMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-2607
Mailing Address - Country:US
Mailing Address - Phone:562-529-8526
Mailing Address - Fax:
Practice Address - Street 1:14101 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-2607
Practice Address - Country:US
Practice Address - Phone:562-529-8526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44488122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist