Provider Demographics
NPI:1235675455
Name:ALBERDA, JACOB TODD (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:TODD
Last Name:ALBERDA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 PEELER ST STE B
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2380
Mailing Address - Country:US
Mailing Address - Phone:269-345-8618
Mailing Address - Fax:269-345-1508
Practice Address - Street 1:900 PEELER ST STE B
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2380
Practice Address - Country:US
Practice Address - Phone:269-345-8618
Practice Address - Fax:269-345-1508
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704275581367500000X
IN28233723367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704275581OtherMICHIGAN LICENSE