Provider Demographics
NPI:1700194750
Name:FUNK, JACOB (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:FUNK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-2266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 TERMINAL DR
Practice Address - Street 2:SUITE 15
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2268
Practice Address - Country:US
Practice Address - Phone:618-258-8610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011766111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor