Provider Demographics
NPI:1346996295
Name:PERREIRA, JACOB MANUEL (AGPCNP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MANUEL
Last Name:PERREIRA
Suffix:
Gender:M
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5843 MINDEN DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221-9379
Mailing Address - Country:US
Mailing Address - Phone:815-474-7660
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-988-1772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28251946A163WM0705X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical