Provider Demographics
NPI:1861001562
Name:ILLISH, JACOB ALEXANDER
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:ALEXANDER
Last Name:ILLISH
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 1:4125 BLACKHAWK PLAZA CIR STE 230
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4648
Mailing Address - Country:US
Mailing Address - Phone:844-262-8466
Mailing Address - Fax:
Practice Address - Street 1:4125 BLACKHAWK PLAZA CIR STE 230
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4648
Practice Address - Country:US
Practice Address - Phone:844-262-8466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician