Provider Demographics
NPI:1245285931
Name:J. BRUCE JACOBS, MD, INC
Entity type:Organization
Organization Name:J. BRUCE JACOBS, MD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-584-3333
Mailing Address - Street 1:2680 SATURN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4377
Mailing Address - Country:US
Mailing Address - Phone:323-584-3333
Mailing Address - Fax:323-584-3336
Practice Address - Street 1:2680 SATURN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4377
Practice Address - Country:US
Practice Address - Phone:323-584-3333
Practice Address - Fax:323-584-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADO242AMedicare PIN