Provider Demographics
NPI:1821217100
Name:JACOBS, BETH (PHD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 CRAWFORD AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4970
Mailing Address - Country:US
Mailing Address - Phone:312-787-4011
Mailing Address - Fax:
Practice Address - Street 1:2530 CRAWFORD AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4970
Practice Address - Country:US
Practice Address - Phone:312-787-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
957770Medicare ID - Type Unspecified