Healthcare Provider Details

I. General information

NPI: 1871457515
Provider Name (Legal Business Name): JACOB LUM PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 S PROMONTORY DR
CHICAGO IL
60649-1002
US

IV. Provider business mailing address

5048 N MARINE DR APT D3
CHICAGO IL
60640-3200
US

V. Phone/Fax

Practice location:
  • Phone: 773-363-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.029169
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: