Basic Information
| Provider Information | |||||||||
| NPI: | 1487739637 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | MARY LYNN | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 UNIVERSITY DR | ||||||||
| Address2: | SUITE A-6 | ||||||||
| City: | AMHERST | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010022473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133665703 | ||||||||
| FaxNumber: | 4139922019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | 1391 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 043527497 | 01 | MA | GREATWEST | OTHER | 11222870 | 01 | CAQH | OTHER | 4214936 | 01 | MA | AETNA-INDIV # | OTHER | 670001710 | 01 | MA | RAILROAD MEDICARE | OTHER | 0389005 | 05 | MA | MEDICAID | 043527497 | 01 | MA | UNITED HEALTH CARE | OTHER | 972730 | 01 | MA | NETWORK HEALTH | OTHER | 043527497 | 01 | MA | CONSOLIDATED | OTHER | 043527497 | 01 | MA | NORTH REGIONS CLAIMS | OTHER | 9715568 | 05 | MA | MEDICAID | P328227 | 01 | OXFORD | OTHER | 043527497 | 01 | MA | UNICARE/GIC | OTHER | 469635 | 01 | MA | TUFTS-IND # | OTHER | 043527 | 01 | MA | CONNECTICARE | OTHER | 103355100 | 01 | MA | DEPT OF LABOR | OTHER | 7710306 | 01 | MA | CIGNA INDIV # | OTHER | OG0011 | 01 | MA | BC BS GROUP # | OTHER | 000000035317 | 01 | MA | BOSTON HEALTNET | OTHER | 690675 | 01 | MA | TUFTS | OTHER | 043527497 | 01 | MA | CIGNA | OTHER | 043527497 | 01 | MA | AETNA | OTHER | 110001391MA02 | 01 | ANTHEM | OTHER | OT0046 | 01 | MA | BC/BS INDIV PROVIDER # | OTHER |