Provider Demographics
NPI:1285528240
Name:JACOBS, EDWARD (ATC)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 N MAIN ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-1456
Mailing Address - Country:US
Mailing Address - Phone:630-485-8316
Mailing Address - Fax:
Practice Address - Street 1:344 N MAIN ST UNIT D
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-1456
Practice Address - Country:US
Practice Address - Phone:630-485-8316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960057762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty