Provider Demographics
NPI: | 1639788326 |
---|---|
Name: | JACO, JACOB (PA-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | JACOB |
Middle Name: | |
Last Name: | JACO |
Suffix: | |
Gender: | M |
Credentials: | PA-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 515 READ ST |
Mailing Address - Street 2: | |
Mailing Address - City: | EVANSVILLE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47710-1739 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 812-424-9291 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 10455 ORTHOPAEDIC DR |
Practice Address - Street 2: | |
Practice Address - City: | NEWBURGH |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47630-7955 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-424-9291 |
Practice Address - Fax: | 812-421-2722 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2020-07-28 |
Last Update Date: | 2024-03-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | PA2736 | 363A00000X |
IN | 10002987A | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 10002987A | Other | STATE LICENSE |
IN | 300044870 | Medicaid | |
KY | PA2736 | Other | STATE LICENSE |
IN | 847950029 | Other | MEDICARE |
IN | MJ6257516 | Other | DEA |