Provider Demographics
NPI:1821199910
Name:JACOBY, KENNETH E (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:JACOBY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 FLETCHER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4703
Mailing Address - Country:US
Mailing Address - Phone:847-741-3127
Mailing Address - Fax:847-741-3173
Practice Address - Street 1:750 FLETCHER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4703
Practice Address - Country:US
Practice Address - Phone:847-741-3127
Practice Address - Fax:847-741-3173
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04532255OtherBCBS
ILP00206050OtherRAILROAD MEDICARE
IL5432480001OtherDMERC
IL5432480001OtherDMERC
ILT38100Medicare UPIN