Provider Demographics
NPI:1841589785
Name:JACOBS, ASHLEY KEYES
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:KEYES
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10533 LE CONTE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3305
Mailing Address - Country:US
Mailing Address - Phone:310-694-4711
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH ST # 8A
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5504
Practice Address - Country:US
Practice Address - Phone:718-579-6151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267656207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology