MEDICARE: MARK E JACOBS D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	038008275	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	350045727	OTHER	IL	TRICARE MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	01921720	OTHER	IL	BLUE CROSS/BLUE SHIELD IL

General Provider Information

NPI Number	:	1003834326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK E JACOBS D.C.

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

Provider Business Practice Location Address
First Line	:	405 W MAIN ST
Second Line	:
City	:	GENOA
State	:	IL
Zip	:	60135-1164
Country	:	US
Telephone Number	:	815-784-4455
Fax Number	:	815-784-4454

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/03/2010

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Directions to “ MARK E JACOBS D.C.” Practice Location

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