Provider Demographics
NPI:1003834326
Name:JACOBS, MARK E (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:IL
Mailing Address - Zip Code:60135-1164
Mailing Address - Country:US
Mailing Address - Phone:815-784-4455
Mailing Address - Fax:815-784-4454
Practice Address - Street 1:405 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GENOA
Practice Address - State:IL
Practice Address - Zip Code:60135-1164
Practice Address - Country:US
Practice Address - Phone:815-784-4455
Practice Address - Fax:815-784-4454
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008275111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL350045727OtherTRICARE MEDICARE
IL01921720OtherBLUE CROSS/BLUE SHIELD IL
IL01921720OtherBLUE CROSS/BLUE SHIELD IL
IL399730Medicare ID - Type UnspecifiedPROVIDER NUMBER