Provider Demographics
NPI:1225510241
Name:JARZEN, JACOB (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:JARZEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WADSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1383
Mailing Address - Country:US
Mailing Address - Phone:217-243-1517
Mailing Address - Fax:
Practice Address - Street 1:5 WADSWORTH DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1383
Practice Address - Country:US
Practice Address - Phone:217-243-1517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0318251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice