Provider Demographics
NPI:1851108864
Name:KIRBY, JACOB SHANE (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:SHANE
Last Name:KIRBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 W BERRY AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46989-9140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:281 W BERRY AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:IN
Practice Address - Zip Code:46989-9140
Practice Address - Country:US
Practice Address - Phone:765-517-1863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program