Provider Demographics
NPI:1871749275
Name:DARRAGH, JACOB D (PT, ATC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:DARRAGH
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:2555 LINCOLN HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1936
Practice Address - Country:US
Practice Address - Phone:708-481-2323
Practice Address - Fax:708-481-3311
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-015787225100000X
IL096-0017392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK52752Medicare PIN
IL216859007Medicare PIN