Provider Demographics
NPI:1194325357
Name:MCGINNIS, JACOB K (AGACNP-BC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:K
Last Name:MCGINNIS
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-7290
Mailing Address - Country:US
Mailing Address - Phone:540-963-1967
Mailing Address - Fax:
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1387
Practice Address - Country:US
Practice Address - Phone:541-963-8421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202011200NP-PP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty