Provider Demographics
NPI:1164126603
Name:TESTER, JACOB A
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:TESTER
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 1:500 BROOKS ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-2839
Mailing Address - Country:US
Mailing Address - Phone:507-720-8516
Mailing Address - Fax:
Practice Address - Street 1:500 BROOKS ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-2839
Practice Address - Country:US
Practice Address - Phone:507-720-8516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNBC774678171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor