Provider Demographics
NPI:1942497755
Name:JACOB, ABRAHAM (PT)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 159TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3333
Mailing Address - Country:US
Mailing Address - Phone:708-687-4747
Mailing Address - Fax:708-687-4749
Practice Address - Street 1:5320 159TH ST STE 300
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-3333
Practice Address - Country:US
Practice Address - Phone:708-687-4747
Practice Address - Fax:708-687-4749
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7602301OtherAETNA
IL1515389OtherCIGNA
IL1618642OtherBC/ BS
IL7602301OtherAETNA