Provider Demographics
NPI:1528463346
Name:PARK, JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 W TAYLOR ST RM 724W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7232
Mailing Address - Country:US
Mailing Address - Phone:402-314-8567
Mailing Address - Fax:
Practice Address - Street 1:1740 W TAYLOR ST RM 724W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7232
Practice Address - Country:US
Practice Address - Phone:402-314-8567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85-005291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant