Healthcare Provider Details

I. General information

NPI: 1447061353
Provider Name (Legal Business Name): JACOB KWYN ERNST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 W AGENCY RD
WEST BURLINGTON IA
52655-1667
US

IV. Provider business mailing address

5171 DEERFIELD DR
BURLINGTON IA
52601-2507
US

V. Phone/Fax

Practice location:
  • Phone: 319-768-5858
  • Fax:
Mailing address:
  • Phone: 319-252-3221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA182849
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: