Provider Demographics
NPI:1063754943
Name:JACOBY CHIROPRACTIC & SPORTS PERFORMANCE
Entity type:Organization
Organization Name:JACOBY CHIROPRACTIC & SPORTS PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-338-7590
Mailing Address - Street 1:1735 N PAULINA ST
Mailing Address - Street 2:#301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1133
Mailing Address - Country:US
Mailing Address - Phone:847-338-7590
Mailing Address - Fax:
Practice Address - Street 1:401 W ONTARIO ST
Practice Address - Street 2:SUITE 150
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-6957
Practice Address - Country:US
Practice Address - Phone:847-338-7590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3801113111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty