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NPI Code Detail

MEDICARE: JACOB C SHIVELY

MEDICARE: JACOB C SHIVELY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse Practitioner71012742AIN

General Provider Information

NPI Number : 1215672928
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB C SHIVELY
Provider Business Mailing Address
First Line : 120 W 22ND ST STE 200
Second Line :
City : OAK BROOK
State : IL
Zip : 60523-1563
Country : US
Telephone Number : 630-573-5000
Fax Number :
Provider Business Practice Location Address
First Line : 11104 PARKVIEW CIRCLE DR STE 330
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1674
Country : US
Telephone Number : 260-494-3484
Fax Number : 260-969-0188
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/28/2022
Last Update Date : 11/01/2023

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