MEDICARE: JEENA JACOB INC.

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	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1275705592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEENA JACOB INC.

Provider Business Mailing Address
First Line	:	1173 ANCIENT OAKS CT
Second Line	:
City	:	BARTLETT
State	:	IL
Zip	:	60103-1711
Country	:	US
Telephone Number	:	847-912-8958
Fax Number	:

Provider Business Practice Location Address
First Line	:	1721 MOON LAKE BLVD STE 150
Second Line	:
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1069
Country	:	US
Telephone Number	:	847-519-3650
Fax Number	:	847-519-3652

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEENA GEORGE JACOB
Credential	:	PSY.D.
Telephone Number	:	847-912-8958

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	03/26/2008

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