Provider Demographics
NPI:1629402839
Name:CHAN-JACOBS, LINDA (DMD)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:
Last Name:CHAN-JACOBS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 E WACKER DR
Mailing Address - Street 2:APT. # 4112
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5229
Mailing Address - Country:US
Mailing Address - Phone:617-909-5227
Mailing Address - Fax:
Practice Address - Street 1:429 S LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1210
Practice Address - Country:US
Practice Address - Phone:906-786-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029499122300000X
MI2901020898122300000X
IL0210025121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist