1114902483 NPI number — DR. REBECCA E JACOBSON MD

Table of content: DR. REBECCA E JACOBSON MD (NPI 1114902483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114902483 NPI number — DR. REBECCA E JACOBSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBSON
Provider First Name:
REBECCA
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COOK
Provider Other First Name:
REBECCA
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114902483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 RIDGE AVE STE 1223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60201-1700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-905-3288
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 N WESTMORELAND RD
Provider Second Line Business Practice Location Address:
STE 228
Provider Business Practice Location Address City Name:
LAKE FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60045-1674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-234-3860
Provider Business Practice Location Address Fax Number:
847-234-3981
Provider Enumeration Date:
12/09/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  036109162 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)