Provider Demographics
NPI:1760632673
Name:JACOB, LUCIENNE (OD)
Entity Type:Individual
Prefix:DR
First Name:LUCIENNE
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 PITKIN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-5045
Mailing Address - Country:US
Mailing Address - Phone:718-342-4300
Mailing Address - Fax:718-554-1553
Practice Address - Street 1:1619 PITKIN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5045
Practice Address - Country:US
Practice Address - Phone:718-342-4300
Practice Address - Fax:718-554-1553
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-27
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007199152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist