Provider Demographics
NPI:1275880429
Name:MUCKERMAN, JACOB LOUIS (FNP BC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LOUIS
Last Name:MUCKERMAN
Suffix:
Gender:M
Credentials:FNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 BROADWAY ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-4566
Mailing Address - Country:US
Mailing Address - Phone:573-339-1957
Mailing Address - Fax:573-339-9709
Practice Address - Street 1:1723 BROADWAY ST
Practice Address - Street 2:SUITE 410
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4566
Practice Address - Country:US
Practice Address - Phone:573-339-1957
Practice Address - Fax:573-339-9709
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012027450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2012027450OtherMEDICAL LICENSE