Provider Demographics
NPI:1164724019
Name:ROSSER, JACOB (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:ROSSER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 W DIVERSEY PWKY UNIT G-2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1201
Mailing Address - Country:US
Mailing Address - Phone:773-236-8566
Mailing Address - Fax:773-257-7553
Practice Address - Street 1:3257 N SHEFFIELD AVE STE 118
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2276
Practice Address - Country:US
Practice Address - Phone:309-868-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009553103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical