Provider Demographics
NPI:1871225045
Name:JACOBS, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6813 MANCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8548
Mailing Address - Country:US
Mailing Address - Phone:618-353-4315
Mailing Address - Fax:
Practice Address - Street 1:27 AUERBACH PL
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1596
Practice Address - Country:US
Practice Address - Phone:618-288-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057002769224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant