Healthcare Provider Details

I. General information

NPI: 1326765793
Provider Name (Legal Business Name): JACOB ERICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12605 E 16TH AVE
AURORA CO
80045-2545
US

IV. Provider business mailing address

PO BOX 110429
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 720-777-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN.0998154-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPN.0998154-NP
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: