Healthcare Provider Details

I. General information

NPI: 1750606596
Provider Name (Legal Business Name): MISS KIMBERLY KAY JAKOB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 N LASALLE ST
CHICAGO IL
60614-6005
US

IV. Provider business mailing address

1447 TRUMAN DR
BRADLEY IL
60915-1466
US

V. Phone/Fax

Practice location:
  • Phone: 312-943-3600
  • Fax:
Mailing address:
  • Phone: 815-936-0342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: