Basic Information
| Provider Information | |||||||||
| NPI: | 1093480832 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | LEENU | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 CASS AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864687370 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2061 N SQUIRREL RD UNIT 1976 | ||||||||
| Address2: | |||||||||
| City: | AUBURN HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483262350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482433710 | ||||||||
| FaxNumber: | 2482821756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2021 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901005572 | MI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.