Healthcare Provider Details

I. General information

NPI: 1215867924
Provider Name (Legal Business Name): JACOB RICHARD VINCENT
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 HERITAGE DR UNIT 1
CRYSTAL LAKE IL
60014-8051
US

IV. Provider business mailing address

282 HABER RD
CARY IL
60013-3236
US

V. Phone/Fax

Practice location:
  • Phone: 847-376-9191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-508201
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: