Provider Demographics
NPI:1275631962
Name:JACOB, GARY ALLAN (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALLAN
Last Name:JACOB
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 VIA DE LA PAZ
Mailing Address - Street 2:SUITE F-1
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-3629
Mailing Address - Country:US
Mailing Address - Phone:310-559-8276
Mailing Address - Fax:310-559-8263
Practice Address - Street 1:860 VIA DE LA PAZ
Practice Address - Street 2:SUITE F-1
Practice Address - City:PACIFIC PALISADES
Practice Address - State:CA
Practice Address - Zip Code:90272-3629
Practice Address - Country:US
Practice Address - Phone:310-559-8276
Practice Address - Fax:310-559-8263
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC12432111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC12432Medicare ID - Type Unspecified