Provider Demographics
NPI:1871810879
Name:JACOB, LISA ROSELIN (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ROSELIN
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6199 WINCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4800
Mailing Address - Country:US
Mailing Address - Phone:610-247-1086
Mailing Address - Fax:
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:313-205-8581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036138036207L00000X
MI4301109137207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology