Provider Demographics
NPI:1659486751
Name:JACOB, MARK B
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
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 1:809 S MARSHFIELD AVE
Mailing Address - Street 2:9TH FLOOR (M/C 732)
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4305
Mailing Address - Country:US
Mailing Address - Phone:312-996-7699
Mailing Address - Fax:312-996-1001
Practice Address - Street 1:1893 SHERIDAN RD STE 311
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2646
Practice Address - Country:US
Practice Address - Phone:847-433-6636
Practice Address - Fax:847-433-2090
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL021.002059204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery