Healthcare Provider Details

I. General information

NPI: 1306667423
Provider Name (Legal Business Name): ANSHU JACOB PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST STE 5-704
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST STE 5-704
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-0061
  • Fax: 312-926-8341
Mailing address:
  • Phone: 312-695-0061
  • Fax: 312-926-8341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010976
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA066100
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: