Healthcare Provider Details

I. General information

NPI: 1003818733
Provider Name (Legal Business Name): JACOB MANOJ KITCHENER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N 9TH ST
SPRINGFIELD IL
62702
US

IV. Provider business mailing address

421 N 9TH ST
SPRINGFIELD IL
62702-5317
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-6868
  • Fax: 177-576-8672
Mailing address:
  • Phone: 217-757-6868
  • Fax: 177-576-8672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number036111221
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number35.086697
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2009027338
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036111221
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number35-08-6697-K
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: