Provider Demographics
NPI:1790147593
Name:CONNELLY, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 CAPE CORAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-8551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:737 CAPE CORAL PKWY E
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-8551
Practice Address - Country:US
Practice Address - Phone:239-542-0512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9409391163W00000X
FL11005429363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse