Provider Demographics
NPI:1225665417
Name:RICKOLL, JACOB ROBERT (NP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:RICKOLL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 CANAL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6110
Mailing Address - Country:US
Mailing Address - Phone:504-613-0315
Mailing Address - Fax:888-498-4941
Practice Address - Street 1:3637 CANAL ST STE 100
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6110
Practice Address - Country:US
Practice Address - Phone:504-613-0315
Practice Address - Fax:888-498-4941
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2023-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA214020363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology