Provider Demographics
NPI:1790034023
Name:GARY PHILLIP JACOBS, M.D., INC.
Entity Type:Organization
Organization Name:GARY PHILLIP JACOBS, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-360-1556
Mailing Address - Street 1:21500 PIONEER BLVD
Mailing Address - Street 2:#210
Mailing Address - City:HAWAIIAN GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90716-2600
Mailing Address - Country:US
Mailing Address - Phone:562-360-1556
Mailing Address - Fax:562-786-8629
Practice Address - Street 1:21500 PIONEER BLVD
Practice Address - Street 2:#210
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-2600
Practice Address - Country:US
Practice Address - Phone:562-360-1556
Practice Address - Fax:562-786-8629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42016207R00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty