Provider Demographics
NPI:1912575390
Name:JACOB, SUSAN M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BRIGGS RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-6337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41 BURLINGTON MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA288809208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery