Healthcare Provider Details

I. General information

NPI: 1346996295
Provider Name (Legal Business Name): JACOB MANUEL PERREIRA AGPCNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

5843 MINDEN DR
INDIANAPOLIS IN
46221-9379
US

V. Phone/Fax

Practice location:
  • Phone: 317-988-1772
  • Fax:
Mailing address:
  • Phone: 815-474-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number28251946A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number28251946A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: