Provider Demographics
NPI:1831136019
Name:JACOB, SUSAN (MC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:MC
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:JOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7009
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-7009
Mailing Address - Country:US
Mailing Address - Phone:630-893-8161
Mailing Address - Fax:630-893-8564
Practice Address - Street 1:303 E ARMY TRAIL RD
Practice Address - Street 2:STE 410A
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2169
Practice Address - Country:US
Practice Address - Phone:630-893-8161
Practice Address - Fax:630-893-8564
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-110462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-110462Medicaid
CN4921OtherRRMC
209398OtherGROUP MEDICARE PTAN
BJ8988214OtherDEA
209398OtherGROUP MEDICARE PTAN