MEDICARE: JEENA JACOB APRN

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	363LA2200X	Adult Health Nurse Practitioner	95016908	CA

General Provider Information

NPI Number	:	1316522253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEENA JACOB APRN

Provider Business Mailing Address
First Line	:	985 W VERNON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-3038
Country	:	US
Telephone Number	:	323-234-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	985 W VERNON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-3038
Country	:	US
Telephone Number	:	323-234-6300
Fax Number	:

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

Provider Enumeration Date	:	03/12/2021
Last Update Date	:	10/31/2022

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