Provider Demographics
NPI:1073125126
Name:WRIGHT, JACOB MICHAEL
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:MICHAEL
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 WINDY OAK DR
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:IN
Mailing Address - Zip Code:46341-9768
Mailing Address - Country:US
Mailing Address - Phone:219-765-0016
Mailing Address - Fax:
Practice Address - Street 1:1409 W CARROLL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1105
Practice Address - Country:US
Practice Address - Phone:312-733-0883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician