MEDICARE: JOHN JACOBS III NP-C

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
1	363LF0000X	Family Nurse Practitioner	APN.0990808-NP	CO
2	363LF0000X	Family Nurse Practitioner	RN2259982	MA
3	363LA2100X	Acute Care Nurse Practitioner	34286.1346	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497184378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN JACOBS III NP-C

Provider Business Mailing Address
First Line	:	3236 E GRAND AVE STE D
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-5100
Country	:	US
Telephone Number	:	307-760-8602
Fax Number	:	307-460-9880

Provider Business Practice Location Address
First Line	:	3236 E GRAND AVE STE D
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-5100
Country	:	US
Telephone Number	:	307-760-8602
Fax Number	:	307-460-9880

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2013
Last Update Date	:	11/14/2018

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