Provider Demographics
NPI:1851046247
Name:JACOB, JIBI (CNP)
Entity Type:Individual
Prefix:MRS
First Name:JIBI
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8112 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3520 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:STONE PARK
Practice Address - State:IL
Practice Address - Zip Code:60165-1042
Practice Address - Country:US
Practice Address - Phone:708-356-6341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024796363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily