Provider Demographics
NPI:1487739637
Name:JACOBS, MARY LYNN (OT)
Entity type:Individual
Prefix:
First Name:MARY LYNN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:101 UNIVERSITY DR
Practice Address - Street 2:SUITE A-6
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2473
Practice Address - Country:US
Practice Address - Phone:413-366-5703
Practice Address - Fax:413-992-2019
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XH1200X
MA1391225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA043527497OtherGREATWEST
11222870OtherCAQH
MA4214936OtherAETNA-INDIV #
MA670001710OtherRAILROAD MEDICARE
MA0389005Medicaid
MA043527497OtherUNITED HEALTH CARE
MA972730OtherNETWORK HEALTH
MA043527497OtherCONSOLIDATED
MA043527497OtherNORTH REGIONS CLAIMS
MA9715568Medicaid
P328227OtherOXFORD
MA043527497OtherUNICARE/GIC
MA469635OtherTUFTS-IND #
MA043527OtherCONNECTICARE
MA103355100OtherDEPT OF LABOR
MA7710306OtherCIGNA INDIV #
MAOG0011OtherBC BS GROUP #
MA000000035317OtherBOSTON HEALTNET
MA690675OtherTUFTS
MA043527497OtherCIGNA
MA043527497OtherAETNA
110001391MA02OtherANTHEM
MAOT0046OtherBC/BS INDIV PROVIDER #
MA469635OtherTUFTS-IND #
MA670001710OtherRAILROAD MEDICARE
MAOG0011OtherBC BS GROUP #