Provider Demographics
NPI:1609402890
Name:HALL, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HALL
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 1:100 E WALTON ST APT 17G
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1415
Mailing Address - Country:US
Mailing Address - Phone:505-715-8498
Mailing Address - Fax:
Practice Address - Street 1:31ST MEDICAL GROUP/SGHC
Practice Address - Street 2:UNIT 6180
Practice Address - City:APO
Practice Address - State:APO
Practice Address - Zip Code:09604
Practice Address - Country:IT
Practice Address - Phone:505-715-8498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102206772208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program