Healthcare Provider Details

I. General information

NPI: 1073247748
Provider Name (Legal Business Name): JACOB L CREEVAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2022
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 PINE LAKE RD
LINCOLN NE
68516-3389
US

IV. Provider business mailing address

5500 PINE LAKE RD
LINCOLN NE
68516-3389
US

V. Phone/Fax

Practice location:
  • Phone: 402-489-8888
  • Fax: 402-421-1945
Mailing address:
  • Phone: 402-489-8888
  • Fax: 402-421-1945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2777
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: