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General NPI Number Information
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NPI Number | 1720351299
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Entity Type | Individual
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Provider Name | MRS. JULIE JACOBS
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Gender | Female
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Dates
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Enumeration Date | 02/14/2012
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Last Update Date | 02/14/2012
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Provider Practice Location Address
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Address Line | 7313 N HONORE ST #2
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City | CHICAGO
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State | IL
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Zip | 60626-1794
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Country | US
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Telephone | 773-680-7082
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Fax |
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Provider Business Mailing Address
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Address Line | 2242 W ROSCOE ST #3
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City | CHICAGO
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State | IL
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Zip | 60618-6391
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | J21242885605
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License Number State | IL
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