Provider Demographics
NPI:1417797762
Name:RICCIO, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:RICCIO
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 1:1922 W OGDEN AVE UNIT 1413
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-5586
Mailing Address - Country:US
Mailing Address - Phone:480-358-8312
Mailing Address - Fax:
Practice Address - Street 1:1620 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3801
Practice Address - Country:US
Practice Address - Phone:888-352-7874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program