Provider Demographics
NPI:1558083659
Name:MCGINNIS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MCGINNIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:OVERDURFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:139 LYME RD
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-6605
Mailing Address - Country:US
Mailing Address - Phone:727-286-0231
Mailing Address - Fax:
Practice Address - Street 1:139 LYME RD
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-6605
Practice Address - Country:US
Practice Address - Phone:727-286-0231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH088938-21163W00000X
NH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse