Provider Demographics
NPI:1962210765
Name:ANHALT, JACOB TIMOTHY
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:TIMOTHY
Last Name:ANHALT
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 1:2624 BROOKSIDE LN APT 805
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-6333
Mailing Address - Country:US
Mailing Address - Phone:608-338-4298
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 440
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3836
Practice Address - Country:US
Practice Address - Phone:312-563-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-25
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.016355225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty