MEDICARE: DR. ELLEN RACHAEL JACOBS 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	103TC0700X	Clinical Psychologist	PSY11462	CA

General Provider Information

NPI Number	:	1598981185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN RACHAEL JACOBS PH.D.

Provider Business Mailing Address
First Line	:	643 FERN GLN
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92037-5419
Country	:	US
Telephone Number	:	858-459-5132
Fax Number	:

Provider Business Practice Location Address
First Line	:	7734 HERSCHEL AVE
Second Line	:	STE E
City	:	LA JOLLA
State	:	CA
Zip	:	92037-4433
Country	:	US
Telephone Number	:	858-459-6341
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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