1003834326 NPI number — MARK E JACOBS D.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003834326 NPI number — MARK E JACOBS D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBS
Provider First Name:
MARK
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003834326
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GENOA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60135-1164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-784-4455
Provider Business Mailing Address Fax Number:
815-784-4454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GENOA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60135-1164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-784-4455
Provider Business Practice Location Address Fax Number:
815-784-4454
Provider Enumeration Date:
07/17/2006

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: 111N00000X , with the licence number:  038008275 , 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)

  • Identifier: 350045727 . This is a "TRICARE MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01921720 . This is a "BLUE CROSS/BLUE SHIELD IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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