Provider Demographics
NPI:1003673997
Name:VANDYKE, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VANDYKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 CRIMSONROSE RUN
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-5664
Mailing Address - Country:US
Mailing Address - Phone:614-214-9290
Mailing Address - Fax:
Practice Address - Street 1:518 CRIMSONROSE RUN
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-5664
Practice Address - Country:US
Practice Address - Phone:614-214-9290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle