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General NPI Number Information
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NPI Number | 1275880429
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Entity Type | Individual
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Provider Name | JACOB LOUIS MUCKERMAN FNP BC
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Gender | Male
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Dates
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Enumeration Date | 08/07/2012
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Last Update Date | 06/05/2024
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Provider Practice Location Address
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Address Line | 1723 BROADWAY ST SUITE 410
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City | CAPE GIRARDEAU
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State | MO
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Zip | 63701-4566
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Country | US
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Telephone | 573-339-1957
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Fax | 573-339-9709
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Provider Business Mailing Address
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Address Line | 1723 BROADWAY ST SUITE 410
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City | CAPE GIRARDEAU
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State | MO
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Zip | 63701-4566
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Country | US
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Telephone | 573-339-1957
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Fax | 573-339-9709
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2012027450
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License Number State | MO
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