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General NPI Number Information
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NPI Number | 1962210765
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Entity Type | Individual
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Provider Name | JACOB TIMOTHY ANHALT
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Gender | Male
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Dates
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Enumeration Date | 12/25/2024
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Last Update Date | 12/30/2024
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Provider Practice Location Address
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Address Line | 1725 W HARRISON ST STE 440
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City | CHICAGO
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State | IL
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Zip | 60612-3836
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Country | US
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Telephone | 312-563-2454
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Fax |
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Provider Business Mailing Address
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Address Line | 2624 BROOKSIDE LN APT 805
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City | SCHAUMBURG
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State | IL
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Zip | 60173-6333
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Country | US
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Telephone | 608-338-4298
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 056.016355
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License Number State | IL
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