Provider Demographics
NPI:1679274468
Name:JACOB, DOLMA TREESA (RN)
Entity Type:Individual
Prefix:MRS
First Name:DOLMA
Middle Name:TREESA
Last Name:JACOB
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 RUE FORET
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1543
Mailing Address - Country:US
Mailing Address - Phone:847-370-0710
Mailing Address - Fax:
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3048
Practice Address - Country:US
Practice Address - Phone:224-610-7567
Practice Address - Fax:224-610-7568
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.404168163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care