Provider Demographics
NPI:1578036091
Name:DEBONI, JACOB R (FNP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:DEBONI
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 E. PARKDALE
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660
Mailing Address - Country:US
Mailing Address - Phone:231-398-1735
Mailing Address - Fax:231-398-1736
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-8904
Practice Address - Country:US
Practice Address - Phone:231-398-1840
Practice Address - Fax:231-398-1835
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily