Provider Demographics
NPI:1740599646
Name:JACOBS, AMANDA J (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:JACOBS
Suffix:
Gender:F
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 1:980 S SAINT AUGUSTINE ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:WI
Mailing Address - Zip Code:54162-9453
Mailing Address - Country:US
Mailing Address - Phone:920-822-7700
Mailing Address - Fax:
Practice Address - Street 1:980 S SAINT AUGUSTINE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:WI
Practice Address - Zip Code:54162-9453
Practice Address - Country:US
Practice Address - Phone:920-822-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100016926Medicaid