Provider Demographics
NPI:1477677037
Name:JACOB, LILY F (MD)
Entity Type:Individual
Prefix:DR
First Name:LILY
Middle Name:F
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1304 GREENMONT CIR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-3294
Mailing Address - Country:US
Mailing Address - Phone:304-295-8985
Mailing Address - Fax:
Practice Address - Street 1:2121 7TH ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3803
Practice Address - Country:US
Practice Address - Phone:304-485-1721
Practice Address - Fax:304-485-6710
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV14446OtherWV MEDICAL LICENSE
WVBJ0186153OtherWV DEA
WVF17392Medicare UPIN