Healthcare Provider Details

I. General information

NPI: 1770515181
Provider Name (Legal Business Name): MICHAEL G. JAKOBY SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 N RUTLEDGE ST STE 2300
SPRINGFIELD IL
62702-4968
US

IV. Provider business mailing address

PO BOX 19636
SPRINGFIELD IL
62794-9636
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-3821
  • Fax: 217-545-9125
Mailing address:
  • Phone: 217-545-3821
  • Fax: 217-545-9125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number036-106808
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: