Healthcare Provider Details

I. General information

NPI: 1336830454
Provider Name (Legal Business Name): JACOB FLOYD KEULTJES MSN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ARCADE AVE STE 320
ELKHART IN
46514-2477
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-523-7900
  • Fax: 574-523-7909
Mailing address:
  • Phone: 574-647-2713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28215465A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: