Provider Demographics
NPI:1598025520
Name:JACOB, MATHEW
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:JACOB
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 1:16228 RYEHILL CIR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5392
Mailing Address - Country:US
Mailing Address - Phone:773-817-1563
Mailing Address - Fax:
Practice Address - Street 1:16228 RYEHILL CIR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5392
Practice Address - Country:US
Practice Address - Phone:773-817-1563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009554A2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics