Provider Demographics
NPI:1316627813
Name:EBNER, JACOB MARK (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MARK
Last Name:EBNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:PITTSGROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-3830
Mailing Address - Country:US
Mailing Address - Phone:856-275-5492
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 1070
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-1663
Practice Address - Fax:302-733-4533
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0012175363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant