Provider Demographics
NPI:1265787998
Name:JACOB, ANISHA (OD)
Entity type:Individual
Prefix:DR
First Name:ANISHA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18920 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1072
Mailing Address - Country:US
Mailing Address - Phone:708-969-3218
Mailing Address - Fax:
Practice Address - Street 1:106 EAST BARNETT AVE
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:IL
Practice Address - Zip Code:62535
Practice Address - Country:US
Practice Address - Phone:217-877-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010568152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist