Provider Demographics
NPI:1902575822
Name:SELPH, THERAN JACOB JR (BS)
Entity Type:Individual
Prefix:MR
First Name:THERAN
Middle Name:JACOB
Last Name:SELPH
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:MR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:SELPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS
Mailing Address - Street 1:240 E HURON ST STE 1-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2909
Mailing Address - Country:US
Mailing Address - Phone:312-503-7975
Mailing Address - Fax:
Practice Address - Street 1:240 E HURON ST STE 1-200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2909
Practice Address - Country:US
Practice Address - Phone:312-503-7975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program