Provider Demographics
NPI:1831160381
Name:WEBER, JACOB CLIFFORD (MPT)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:CLIFFORD
Last Name:WEBER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 CYPRESS RD
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-4339
Mailing Address - Country:US
Mailing Address - Phone:618-925-3973
Mailing Address - Fax:
Practice Address - Street 1:216 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1548
Practice Address - Country:US
Practice Address - Phone:618-382-2923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-013499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist