Basic Information
| Provider Information | |||||||||
| NPI: | 1689033599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | JAMIE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 APEX DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184410482 | ||||||||
| FaxNumber: | 6184410482 | ||||||||
| Practice Location | |||||||||
| Address1: | 2611 S BANKER ST | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172804550 | ||||||||
| FaxNumber: | 2172804551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2016 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070022044 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.