Provider Demographics
NPI:1114505807
Name:FITZPATRICK, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FITZPATRICK
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 1:5830 N LAPEER RD STE B-D
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48461-9660
Mailing Address - Country:US
Mailing Address - Phone:810-545-0235
Mailing Address - Fax:810-545-0409
Practice Address - Street 1:5830 N LAPEER RD STE B&C
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48461-9660
Practice Address - Country:US
Practice Address - Phone:810-545-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704336069363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily