Provider Demographics
NPI:1104380880
Name:PANKA, JACOB J (ND, MS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:J
Last Name:PANKA
Suffix:
Gender:M
Credentials:ND, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 6TH AVE N APT 316
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-1630
Mailing Address - Country:US
Mailing Address - Phone:612-568-8382
Mailing Address - Fax:
Practice Address - Street 1:3041 ALDRICH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408
Practice Address - Country:US
Practice Address - Phone:612-568-8382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-26
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1099175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1099OtherNATUROPATHIC DOCTOR