Provider Demographics
NPI:1104088996
Name:JACOB, JINCY
Entity type:Individual
Prefix:
First Name:JINCY
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JINCY
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:832 S GREVILLEA AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-3312
Mailing Address - Country:US
Mailing Address - Phone:310-419-4354
Mailing Address - Fax:310-419-4621
Practice Address - Street 1:832 S GREVILLEA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-3312
Practice Address - Country:US
Practice Address - Phone:310-419-4354
Practice Address - Fax:310-419-4621
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10032427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine