Provider Demographics
NPI:1003818733
Name:KITCHENER, JACOB MANOJ (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MANOJ
Last Name:KITCHENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5317
Mailing Address - Country:US
Mailing Address - Phone:217-757-6868
Mailing Address - Fax:177-576-8672
Practice Address - Street 1:421 N 9TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-757-6868
Practice Address - Fax:177-576-8672
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090273382084N0400X
OH35-08-6697-K2084N0600X
OH35.0866972084V0102X
IL0361112212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2612015Medicaid
OH2612015Medicaid
OHI37762Medicare UPIN
OHH104750Medicare PIN