Provider Demographics
NPI:1952753162
Name:THOMAS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:THOMAS
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 1:610 S PARK CREST DR
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-7802
Mailing Address - Country:US
Mailing Address - Phone:815-233-3277
Mailing Address - Fax:815-232-2268
Practice Address - Street 1:610 S PARK CREST DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-7802
Practice Address - Country:US
Practice Address - Phone:815-233-3277
Practice Address - Fax:815-232-2268
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3262237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist