Provider Demographics
NPI:1730506106
Name:GARVER, JACOB (ATC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:GARVER
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 1:910 W 19TH PL
Mailing Address - Street 2:BSMT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-3426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39 W. BANKVIEW DR.
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423
Practice Address - Country:US
Practice Address - Phone:815-464-7113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0024882255A2300X
IL003962246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer