Provider Demographics
NPI:1689074080
Name:JACOB, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
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 1:4150 EASTGATE DR
Mailing Address - Street 2:APT 7308
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32738
Mailing Address - Country:US
Mailing Address - Phone:321-246-8080
Mailing Address - Fax:
Practice Address - Street 1:4150 EASTGATE DR
Practice Address - Street 2:APT 7308
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32738
Practice Address - Country:US
Practice Address - Phone:321-246-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program