Provider Demographics
NPI:1972848638
Name:JESSIE JACOB MD INC
Entity Type:Organization
Organization Name:JESSIE JACOB MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-282-6171
Mailing Address - Street 1:900 WELCH RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1805
Mailing Address - Country:US
Mailing Address - Phone:650-617-8655
Mailing Address - Fax:
Practice Address - Street 1:900 WELCH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1805
Practice Address - Country:US
Practice Address - Phone:650-617-8655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA107083OtherCALIFORNIA LICENCE