Provider Demographics
NPI:1154485316
Name:JACOBY, CARMEN Y (DC)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:Y
Last Name:JACOBY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:J
Other - Last Name:HOUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:106 W. WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812
Mailing Address - Country:US
Mailing Address - Phone:618-439-2225
Mailing Address - Fax:618-435-5063
Practice Address - Street 1:106 W. WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812
Practice Address - Country:US
Practice Address - Phone:618-439-2225
Practice Address - Fax:618-435-5063
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILH32611068907111N00000X
IL038007662111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02807755OtherBCBS OF IL
IL438191OtherHEALTHLINK
395140Medicare ID - Type Unspecified