Provider Demographics
NPI:1700437753
Name:GISE, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GISE
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 1:1000 SONOMA DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75072-3777
Mailing Address - Country:US
Mailing Address - Phone:918-671-5630
Mailing Address - Fax:
Practice Address - Street 1:1428 W HEBRON PKWY
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6345
Practice Address - Country:US
Practice Address - Phone:918-671-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-21
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143145363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily