=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245285931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J. BRUCE JACOBS, MD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 12/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2680 SATURN AVE SUITE 100
-----------------------------------------------------
City | HUNTINGTON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90255-4377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-584-3333
-----------------------------------------------------
Fax | 323-584-3336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2680 SATURN AVE SUITE 100
-----------------------------------------------------
City | HUNTINGTON PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90255-4377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-584-3333
-----------------------------------------------------
Fax | 323-584-3336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAY BRUCE JACOBS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-584-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------