Healthcare Provider Details

I. General information

NPI: 1790249118
Provider Name (Legal Business Name): JACOB BRADFORD HEKKER MSN, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 CONNABLE AVE
PETOSKEY MI
49770-2212
US

IV. Provider business mailing address

602 JACKSON ST
PETOSKEY MI
49770-2220
US

V. Phone/Fax

Practice location:
  • Phone: 231-348-2795
  • Fax: 231-348-2031
Mailing address:
  • Phone: 231-348-2795
  • Fax: 231-348-2031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704297739
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: