Healthcare Provider Details

I. General information

NPI: 1558993667
Provider Name (Legal Business Name): JACOB JAMES BALLARD MSN, APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 HOBART ST
CADILLAC MI
49601-2379
US

IV. Provider business mailing address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2345
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-2644
  • Fax:
Mailing address:
  • Phone: 231-392-0421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704293945
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: