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General NPI Number Information
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NPI Number | 1205330628
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Entity Type | Organization
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Legal Business Name | MELISSA JACOB
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Dates
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Enumeration Date | 03/20/2018
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Last Update Date | 04/17/2018
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Provider Practice Location Address
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Address Line | 420 N WOLF RD
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City | NORTHLAKE
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State | IL
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Zip | 60164-1670
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Country | US
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Telephone | 708-562-4300
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Fax |
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Provider Business Mailing Address
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Address Line | 3N464 PATRICIA LN
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City | ELMHURST
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State | IL
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Zip | 60126-1210
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Country | US
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Telephone | 630-850-0994
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Fax |
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Authorized Official
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Title or Position | HUMAN RESOURCE ASSISTANT
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Name | KENT G LATTANZI
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Credential |
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Telephone | 410-667-7200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 070022999
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License Number State | IL
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