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General NPI Number Information
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NPI Number | 1104513522
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Entity Type | Individual
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Provider Name | JACOB VANCE
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Gender | Male
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Dates
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Enumeration Date | 04/18/2023
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Last Update Date | 04/18/2023
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Provider Practice Location Address
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Address Line | 212 N ROCHESTER ST
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City | MUKWONAGO
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State | WI
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Zip | 53149-1313
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Country | US
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Telephone | 262-363-5235
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Fax |
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Provider Business Mailing Address
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Address Line | 1009 N JACKSON ST APT 1307B
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City | MILWAUKEE
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State | WI
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Zip | 53202-3203
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Country | US
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Telephone | 630-508-5340
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 22126
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License Number State | WI
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