Provider Demographics
NPI:1477548477
Name:JACOBSEN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 OAKMONT LN
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5511
Mailing Address - Country:US
Mailing Address - Phone:630-288-6215
Mailing Address - Fax:630-214-9344
Practice Address - Street 1:1 ERIE CT
Practice Address - Street 2:SUITE 7020
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2566
Practice Address - Country:US
Practice Address - Phone:630-789-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC39218Medicare UPIN
ILL91761Medicare ID - Type UnspecifiedLOCALITY 16