# JACOB JACO

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1639788326
- **Gender:** Man
- **Credential:** PA-C

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363A00000X | Physician Assistant | 10002987A | IN | Yes |
| 363A00000X | Physician Assistant | PA2736 | KY | — |

## Other

- **Enumeration date:** 07/28/2020
- **Last updated:** 03/15/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 10002987A | STATE LICENSE | IN |
| 05 | — | 300044870 | — | IN |
| 01 | — | 847950029 | MEDICARE | IN |
| 01 | — | PA2736 | STATE LICENSE | KY |