Healthcare Provider Details

I. General information

NPI: 1760396659
Provider Name (Legal Business Name): JACOB V LE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EDGEWOOD COLLEGE DR
MADISON WI
53711-1997
US

IV. Provider business mailing address

8201 PLAZA DR APT 215
MADISON WI
53719-3856
US

V. Phone/Fax

Practice location:
  • Phone: 608-663-4299
  • Fax:
Mailing address:
  • Phone: 507-577-9126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number112981630
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: