MEDICARE: PETER A. JAKACKI MD

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	207Q00000X	Family Medicine Physician	01052452A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00989023	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000183064	OTHER		BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669463089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER A. JAKACKI MD

Provider Business Mailing Address
First Line	:	6920 POINTE INVERNESS WAY STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7934
Country	:	US
Telephone Number	:	260-479-3516
Fax Number	:	260-479-3520

Provider Business Practice Location Address
First Line	:	2512 E DUPONT RD
Second Line	:	SUITE 210
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1609
Country	:	US
Telephone Number	:	260-497-0084
Fax Number	:	260-484-2859

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

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	10/01/2020

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Directions to “ PETER A. JAKACKI MD” Practice Location

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