Provider Demographics
NPI:1679850747
Name:JACOBY, KEVIN M (MSN, RN, APNP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:JACOBY
Suffix:
Gender:M
Credentials:MSN, RN, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 N GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-1527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 W CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1650
Practice Address - Country:US
Practice Address - Phone:414-874-4316
Practice Address - Fax:414-874-4160
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4684-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily