Provider Demographics
NPI:1255122206
Name:JACOB, REENU M (PA-C)
Entity type:Individual
Prefix:
First Name:REENU
Middle Name:M
Last Name:JACOB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17400 MAJESTIC CYPRESS WAY
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-5190
Mailing Address - Country:US
Mailing Address - Phone:310-743-6079
Mailing Address - Fax:
Practice Address - Street 1:18112 CA-18 SUITE 101
Practice Address - Street 2:
Practice Address - City:APPLY VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-946-2243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA66143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant