Provider Demographics
NPI:1003574526
Name:JACOB, JUSTIN S (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:S
Last Name:JACOB
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 DOWNING CIR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1029
Mailing Address - Country:US
Mailing Address - Phone:847-739-6792
Mailing Address - Fax:
Practice Address - Street 1:2480 DOWNING CIR
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1029
Practice Address - Country:US
Practice Address - Phone:847-739-6792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.304277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist