Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 038.011644 | IL |
NPI | 1053454140 |
---|---|
Provider Name | Dr. Kim Jacobs Martin |
First Address | Northbrook, IL 60062-5447 |
Second Address | Northbrook, IL 60062-5447 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 30/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U79952 | (02) | KS |