Provider Demographics
NPI:1336830454
Name:KEULTJES, JACOB FLOYD (MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:FLOYD
Last Name:KEULTJES
Suffix:
Gender:M
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-2129
Mailing Address - Fax:574-523-7909
Practice Address - Street 1:500 ARCADE AVE STE 320
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2477
Practice Address - Country:US
Practice Address - Phone:574-523-7900
Practice Address - Fax:574-523-7909
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28215465A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner