MEDICARE: MR. TOBIN JACOB TITO APN-CNP

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
1	363L00000X	Nurse Practitioner	209021978	IL
2	363LG0600X	Gerontology Nurse Practitioner	209.021978	IL

General Provider Information

NPI Number	:	1124616602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TOBIN JACOB TITO APN-CNP

Provider Business Mailing Address
First Line	:	1004 CRYSTAL CT
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60025-2682
Country	:	US
Telephone Number	:	847-431-3838
Fax Number	:

Provider Business Practice Location Address
First Line	:	6308 8TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-5031
Country	:	US
Telephone Number	:	847-431-3838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2021
Last Update Date	:	05/11/2026

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