Provider Demographics
NPI:1215501218
Name:DAIGLE, JACOB DAVID
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DAVID
Last Name:DAIGLE
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 1:25102 THORNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9277
Mailing Address - Country:US
Mailing Address - Phone:715-573-8692
Mailing Address - Fax:
Practice Address - Street 1:265 GRIFFIN ST E
Practice Address - Street 2:
Practice Address - City:AMERY
Practice Address - State:WI
Practice Address - Zip Code:54001-1439
Practice Address - Country:US
Practice Address - Phone:715-268-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1107533-30367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered