Healthcare Provider Details

I. General information

NPI: 1659846426
Provider Name (Legal Business Name): AMANDA JACOB NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA SHOTWELL

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-0633
  • Fax: 248-898-3393
Mailing address:
  • Phone: 947-522-1848
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704294394
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number4704294394
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: