Provider Demographics
NPI:1528016318
Name:JACOUB, JACK F (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:F
Last Name:JACOUB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:18111 BROOKHURST ST STE 6100
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:714-378-7330
Mailing Address - Fax:714-377-0003
Practice Address - Street 1:18111 BROOKHURST ST STE 6100
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-378-7330
Practice Address - Fax:714-377-0003
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA79623207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH60843Medicare UPIN