MEDICARE: DR. BONNIE A JACOBS PSYCOLOGIST

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	PSY13629	CA

General Provider Information

NPI Number	:	1700992047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONNIE A JACOBS PSYCOLOGIST

Provider Business Mailing Address
First Line	:	6404 WILSHIRE BLVD
Second Line	:	SUITE 725
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5501
Country	:	US
Telephone Number	:	323-655-4056
Fax Number	:	323-655-4056

Provider Business Practice Location Address
First Line	:	6404 WILSHIRE BLVD
Second Line	:	SUITE 725
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-5501
Country	:	US
Telephone Number	:	323-655-4056
Fax Number	:	323-655-4056

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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