Provider Demographics
NPI:1801445077
Name:WOLF, JACOB (APRN, CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:APRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1379
Mailing Address - Country:US
Mailing Address - Phone:630-933-6675
Mailing Address - Fax:630-933-2614
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1379
Practice Address - Country:US
Practice Address - Phone:630-933-6675
Practice Address - Fax:630-933-2614
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65596367500000X
MERNA213004367500000X
IL209023753367500000X
CA95127105163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse