Provider Demographics
NPI:1598184517
Name:CONNELLY, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 SE MONTEREY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4512
Mailing Address - Country:US
Mailing Address - Phone:772-288-2400
Mailing Address - Fax:772-419-0143
Practice Address - Street 1:9401 SW DISCOVERY WAY STE 201
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2381
Practice Address - Country:US
Practice Address - Phone:772-288-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME144380207X00000X, 207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine