MEDICARE: DR. SUSAN M. JACOB PH.D.

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	101YP2500X	Professional Counselor	MFT25105	CA

General Provider Information

NPI Number	:	1245246503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN M. JACOB PH.D.

Provider Business Mailing Address
First Line	:	1101 DOVE ST
Second Line	:	SUITE 160
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2839
Country	:	US
Telephone Number	:	949-851-5022
Fax Number	:	949-851-5123

Provider Business Practice Location Address
First Line	:	1101 DOVE ST
Second Line	:	SUITE 160
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-2839
Country	:	US
Telephone Number	:	949-851-5022
Fax Number	:	949-851-5123

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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