Provider Demographics
NPI:1689294258
Name:JACOB, LIDIYA M (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:LIDIYA
Middle Name:M
Last Name:JACOB
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12251 S 80TH AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1290
Mailing Address - Country:US
Mailing Address - Phone:630-257-1111
Mailing Address - Fax:630-257-1115
Practice Address - Street 1:12251 S 80TH AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1290
Practice Address - Country:US
Practice Address - Phone:630-257-1111
Practice Address - Fax:630-257-1115
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021213363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner