MEDICARE: MRS. LAUREN BETTY JACOB MA, TLLP

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	103TC0700X	Clinical Psychologist	L2310588	MI
2	103TC0700X	Clinical Psychologist	6301015300	MI

General Provider Information

NPI Number	:	1518300847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAUREN BETTY JACOB MA, TLLP

Provider Business Mailing Address
First Line	:	2351 W. 12 MILE RD.
Second Line	:
City	:	BERKLEY
State	:	MI
Zip	:	48072-1826
Country	:	US
Telephone Number	:	248-544-4004
Fax Number	:	248-544-4113

Provider Business Practice Location Address
First Line	:	2351 W. 12 MILE RD.
Second Line	:
City	:	BERKLEY
State	:	MI
Zip	:	48072-1826
Country	:	US
Telephone Number	:	248-544-4004
Fax Number	:	248-544-4113

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

Provider Enumeration Date	:	04/17/2013
Last Update Date	:	06/01/2016

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