Provider Demographics
NPI:1932741717
Name:BOEHM, JACOB DALTON (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DALTON
Last Name:BOEHM
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 1:1100 JORIE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2219
Mailing Address - Country:US
Mailing Address - Phone:630-974-6602
Mailing Address - Fax:630-487-2411
Practice Address - Street 1:409 ILLINOIS AVE UNIT 1D
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2966
Practice Address - Country:US
Practice Address - Phone:630-974-6602
Practice Address - Fax:630-487-2411
Is Sole Proprietor?:No
Enumeration Date:2019-10-12
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
IL085.007272363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical