Healthcare Provider Details

I. General information

NPI: 1386040400
Provider Name (Legal Business Name): JESSICA LAUREN JAKOB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 340
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST SUITE 340
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-6715
  • Fax: 312-563-0165
Mailing address:
  • Phone: 312-664-6715
  • Fax: 312-563-0165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004919
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: