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General NPI Number Information
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NPI Number | 1386688331
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Entity Type | Individual
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Provider Name | LISA SUSAN JACOB D.D.S.
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Gender | Female
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Dates
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Enumeration Date | 06/16/2006
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 2810 DACY LN
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City | KYLE
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State | TX
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Zip | 78640-6322
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Country | US
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Telephone | 210-233-7000
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Fax | 512-268-2253
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Provider Business Mailing Address
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Address Line | 1301 BARBARA JORDAN BLVD STE 301
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City | AUSTIN
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State | TX
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Zip | 78723-3078
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Country | US
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Telephone | 512-324-9999
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Fax | 512-324-0645
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 19077
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 19077
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 19077
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License Number State | TX
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