Provider Demographics
NPI:1194564591
Name:BUDKE, JACOB NICHOLAS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:NICHOLAS
Last Name:BUDKE
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 1:3576 COMMONWEALTH RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4379
Mailing Address - Country:US
Mailing Address - Phone:651-276-9169
Mailing Address - Fax:
Practice Address - Street 1:3576 COMMONWEALTH RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4379
Practice Address - Country:US
Practice Address - Phone:651-276-9169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program