Provider Demographics
NPI:1922042449
Name:JACOBS, LAURENCE LIBERTY (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:LIBERTY
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SUPERIOR AVE
Mailing Address - Street 2:310
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2716
Mailing Address - Country:US
Mailing Address - Phone:949-642-6320
Mailing Address - Fax:949-642-6326
Practice Address - Street 1:320 SUPERIOR AVE
Practice Address - Street 2:310
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2716
Practice Address - Country:US
Practice Address - Phone:949-642-6320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA13118174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist