MEDICARE: JESSIE K JACOB MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	242480	NY
2	2085R0202X	Diagnostic Radiology Physician	A107083	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A107083	OTHER	CA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1083644223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIE K JACOB MD

Provider Business Mailing Address
First Line	:	2421 PARK BLVD STE B202
Second Line	:
City	:	PALO ALTO
State	:	CA
Zip	:	94306-1956
Country	:	US
Telephone Number	:	650-617-8655
Fax Number	:

Provider Business Practice Location Address
First Line	:	2421 PARK BLVD STE B202
Second Line	:
City	:	PALO ALTO
State	:	CA
Zip	:	94306-1956
Country	:	US
Telephone Number	:	650-617-8655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	12/30/2020

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