Provider Demographics
NPI:1497184378
Name:JACOBS, JOHN III (NP-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JACOBS
Suffix:III
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3236 E GRAND AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5100
Mailing Address - Country:US
Mailing Address - Phone:307-760-8602
Mailing Address - Fax:307-460-9880
Practice Address - Street 1:3236 E GRAND AVE STE D
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5100
Practice Address - Country:US
Practice Address - Phone:307-760-8602
Practice Address - Fax:307-460-9880
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0990808-NP363LF0000X
MARN2259982363LF0000X
WY34286.1346363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYP01679910Medicaid