Provider Demographics
NPI:1609464627
Name:MCKILLOP, JACOB DAKOTA (PA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DAKOTA
Last Name:MCKILLOP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:D
Other - Last Name:MCKILLOP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:4000 COLISEUM DR STE 445
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5981
Mailing Address - Country:US
Mailing Address - Phone:757-827-2127
Mailing Address - Fax:757-827-2255
Practice Address - Street 1:4000 COLISEUM DR STE 445
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5981
Practice Address - Country:US
Practice Address - Phone:757-827-2127
Practice Address - Fax:757-827-2255
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
VA0110007560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant