Healthcare Provider Details

I. General information

NPI: 1619396207
Provider Name (Legal Business Name): ANN JACOB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W JEFFERSON ST
SPRINGFIELD IL
62702-4833
US

IV. Provider business mailing address

PO BOX 19642 901 WEST JEFFERSON
SPRINGFIELD IL
62794-9642
US

V. Phone/Fax

Practice location:
  • Phone: 312-513-0307
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036149661
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125069375
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: