Individual
MR. KEVIN CHACKO JACOB
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1740 W TAYLOR ST, CHICAGO, IL 60612-7232
(312) 996-2450
Mailing address
4933 N WEAVERRIDGE BLVD, PEORIA, IL 61615-8911
(309) 550-4415
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
125081853
IL
390200000X
Student in an Organized Health Care Education/Training Program
—
IL
Other
Enumeration date
02/28/2022
Last updated
11/01/2023
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