Provider Demographics
NPI:1154940344
Name:WREN, JACOB SCOTT (DNAP, CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:SCOTT
Last Name:WREN
Suffix:
Gender:M
Credentials:DNAP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3153 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2491
Mailing Address - Country:US
Mailing Address - Phone:573-576-3313
Mailing Address - Fax:
Practice Address - Street 1:1701 LACEY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-5230
Practice Address - Country:US
Practice Address - Phone:573-334-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027783163W00000X
390200000X
MO2020017323367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program