Provider Demographics
NPI:1265498083
Name:JACOB, CAROLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N STATE ST STE 900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-9104
Mailing Address - Country:US
Mailing Address - Phone:312-245-9965
Mailing Address - Fax:312-245-9964
Practice Address - Street 1:515 N STATE ST STE 900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654
Practice Address - Country:US
Practice Address - Phone:312-245-9965
Practice Address - Fax:312-245-9964
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102098207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102098Medicaid
IL036102098Medicaid