Provider Demographics
NPI:1639729726
Name:JACOB, CONSTANCE (APRN)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 W 3RD ST N STE 600
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-1223
Mailing Address - Country:US
Mailing Address - Phone:316-660-7600
Mailing Address - Fax:316-941-5075
Practice Address - Street 1:1919 N AMIDON AVE STE 130
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-2118
Practice Address - Country:US
Practice Address - Phone:316-660-7675
Practice Address - Fax:316-941-5075
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS78963363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner