Healthcare Provider Details

I. General information

NPI: 1063026144
Provider Name (Legal Business Name): JACOB COMEAUX LGCG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 BIGGY ST # 2517R
LOS ANGELES CA
90033-1006
US

IV. Provider business mailing address

1450 BIGGY ST # 2517R
LOS ANGELES CA
90033-1006
US

V. Phone/Fax

Practice location:
  • Phone: 323-865-0911
  • Fax:
Mailing address:
  • Phone: 323-865-0933
  • Fax: 323-865-0933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC001244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: