Provider Demographics
NPI:1265083018
Name:WARDACH, JACOB JOSEPH (APRN)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOSEPH
Last Name:WARDACH
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-0655
Mailing Address - Country:US
Mailing Address - Phone:989-736-9815
Mailing Address - Fax:989-358-3734
Practice Address - Street 1:3434 M 119 STE C
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-9373
Practice Address - Country:US
Practice Address - Phone:231-348-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307615363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner