Healthcare Provider Details

I. General information

NPI: 1699449223
Provider Name (Legal Business Name): NICHOLAS ROSS JACOBS DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 W RANDOLPH ST
CHICAGO IL
60607-2215
US

IV. Provider business mailing address

1040 W RANDOLPH ST
CHICAGO IL
60607-2215
US

V. Phone/Fax

Practice location:
  • Phone: 844-277-3611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number019.037492
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: