Provider Demographics
NPI:1104513522
Name:VANCE, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VANCE
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 1:1009 N JACKSON ST APT 1307B
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3203
Mailing Address - Country:US
Mailing Address - Phone:630-508-5340
Mailing Address - Fax:
Practice Address - Street 1:212 N ROCHESTER ST
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-1313
Practice Address - Country:US
Practice Address - Phone:262-363-5235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist