Provider Demographics
NPI:1205330628
Name:MELISSA JACOB
Entity type:Organization
Organization Name:MELISSA JACOB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:G
Authorized Official - Last Name:LATTANZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-667-7200
Mailing Address - Street 1:3N464 PATRICIA LN
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1210
Mailing Address - Country:US
Mailing Address - Phone:630-850-0994
Mailing Address - Fax:
Practice Address - Street 1:420 N WOLF RD
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-1670
Practice Address - Country:US
Practice Address - Phone:708-562-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022999261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy