Provider Demographics
NPI:1386688331
Name:JACOB, LISA SUSAN (DDS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SUSAN
Last Name:JACOB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BARBARA JORDAN BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3077
Mailing Address - Country:US
Mailing Address - Phone:512-324-9999
Mailing Address - Fax:512-324-0645
Practice Address - Street 1:1301 BARBARA JORDAN BLVD
Practice Address - Street 2:SUITE 307
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3077
Practice Address - Country:US
Practice Address - Phone:512-324-9999
Practice Address - Fax:512-324-0645
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19077122300000X, 1223S0112X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery