Provider Demographics
NPI:1104214402
Name:JACOB, LENA (PA-C)
Entity type:Individual
Prefix:
First Name:LENA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LENA
Other - Middle Name:
Other - Last Name:ABRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-7201
Mailing Address - Country:US
Mailing Address - Phone:214-645-8525
Mailing Address - Fax:
Practice Address - Street 1:2280 INWOOD RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-4009
Practice Address - Country:US
Practice Address - Phone:214-645-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA094962085R0001X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8844NUOtherBCBS
TX355290301Medicaid
TX8844NUOtherBCBS