Provider Demographics
NPI:1093473100
Name:FAYIAH, JACOB SAAH
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:SAAH
Last Name:FAYIAH
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 1:62751 ELM RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-9749
Mailing Address - Country:US
Mailing Address - Phone:574-440-2762
Mailing Address - Fax:
Practice Address - Street 1:9998 CROSSPOINT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3307
Practice Address - Country:US
Practice Address - Phone:317-806-8260
Practice Address - Fax:317-806-8296
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011992A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily