Provider Demographics
NPI:1396507273
Name:BOBROW, JACOB BERNARD
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BERNARD
Last Name:BOBROW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 VERNON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1684
Mailing Address - Country:US
Mailing Address - Phone:847-722-4637
Mailing Address - Fax:
Practice Address - Street 1:825 GREEN BAY RD STE 200
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2500
Practice Address - Country:US
Practice Address - Phone:847-251-6630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.112983104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker