Provider Demographics
NPI:1003398157
Name:THOELE, JACOB G (AGACNP-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:G
Last Name:THOELE
Suffix:
Gender:M
Credentials:AGACNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST STE 550
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8366
Practice Address - Country:US
Practice Address - Phone:903-606-8718
Practice Address - Fax:903-606-1218
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137474363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8KC686OtherBCBS
TX391691801Medicaid
TXP02137154OtherMEDICARE RAIL ROAD