Provider Demographics
NPI:1689105413
Name:JACOB-CHARLY, EUNICE SAJAN (DO)
Entity Type:Individual
Prefix:DR
First Name:EUNICE
Middle Name:SAJAN
Last Name:JACOB-CHARLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:EUNICE
Other - Middle Name:SAJAN
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1200 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-490-1600
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-2112
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-490-1881
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.151197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine