Provider Demographics
NPI:1972925790
Name:WARRENS, JACOB R (PA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:R
Last Name:WARRENS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:964 W RYAN ST
Practice Address - Street 2:SUITE B
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110-1517
Practice Address - Country:US
Practice Address - Phone:920-756-2055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1117090OtherNCCPA
WIK400269702Medicare Oscar/Certification