Provider Demographics
NPI:1083351431
Name:JACOB, RYAN E (RN)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:E
Last Name:JACOB
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S 4TH ST STE 111
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1046
Mailing Address - Country:US
Mailing Address - Phone:702-354-2400
Mailing Address - Fax:
Practice Address - Street 1:1200 S 4TH ST STE 111
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1046
Practice Address - Country:US
Practice Address - Phone:702-380-8118
Practice Address - Fax:702-380-2929
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV849303163WC1500X, 163WI0500X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy