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
StateLicense IDTaxonomies
KYPA2736363A00000X
IN10002987A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10002987AOtherSTATE LICENSE
IN300044870Medicaid
KYPA2736OtherSTATE LICENSE
IN847950029OtherMEDICARE
INMJ6257516OtherDEA