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NPI Code Detail

MEDICARE: JACOB CETERA DPT

MEDICARE: JACOB CETERA DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist070022116IL

General Provider Information

NPI Number : 1114378122
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB CETERA DPT
Provider Business Mailing Address
First Line : 1331 W WINONA ST
Second Line : APT. 2
City : CHICAGO
State : IL
Zip : 60640-2909
Country : US
Telephone Number : 773-259-2944
Fax Number :
Provider Business Practice Location Address
First Line : 1331 W WINONA ST
Second Line : APT. 2
City : CHICAGO
State : IL
Zip : 60640-2909
Country : US
Telephone Number : 773-259-2944
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2016
Last Update Date : 06/30/2016

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