Provider Demographics
NPI:1801213962
Name:JACOB, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
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 1:1820 E BOULDER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1961
Mailing Address - Country:US
Mailing Address - Phone:224-475-2433
Mailing Address - Fax:
Practice Address - Street 1:1820 E BOULDER DR
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1961
Practice Address - Country:US
Practice Address - Phone:224-475-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine