Provider Demographics
NPI:1235024639
Name:HOGAN, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HOGAN
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 1:6520 W 700 N
Mailing Address - Street 2:
Mailing Address - City:SHIPSHEWANA
Mailing Address - State:IN
Mailing Address - Zip Code:46565-8505
Mailing Address - Country:US
Mailing Address - Phone:260-350-5018
Mailing Address - Fax:
Practice Address - Street 1:6520 W 700 N
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565-8505
Practice Address - Country:US
Practice Address - Phone:260-350-5018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703112739164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse