Healthcare Provider Details

I. General information

NPI: 1013381128
Provider Name (Legal Business Name): JACOB DANIEL MARLOW H.I.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 E WASHINGTON ST SUITE 2
BLOOMINGTON IL
61704-4497
US

IV. Provider business mailing address

18649 N APACHE PATH
DANVERS IL
61732-9050
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-0622
  • Fax: 309-662-3384
Mailing address:
  • Phone: 309-684-0888
  • Fax: 309-662-3384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3215
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: