Provider Demographics
NPI:1417427543
Name:JOHN, JACOB (PA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 E ZINNIA LN
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-1260
Mailing Address - Country:US
Mailing Address - Phone:847-284-2198
Mailing Address - Fax:
Practice Address - Street 1:8301 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2546
Practice Address - Country:US
Practice Address - Phone:847-674-0455
Practice Address - Fax:847-674-0466
Is Sole Proprietor?:No
Enumeration Date:2018-12-02
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant