Provider Demographics
NPI:1356151492
Name:JACOB, ALISHA (FNP-C)
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W CALDWELL DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-4296
Mailing Address - Country:US
Mailing Address - Phone:847-630-1671
Mailing Address - Fax:
Practice Address - Street 1:515 W CALDWELL DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-4296
Practice Address - Country:US
Practice Address - Phone:847-630-1671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041482764163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse