Provider Demographics
NPI:1033548045
Name:JACOB, MICHELLE VERONICA (AGNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:VERONICA
Last Name:JACOB
Suffix:
Gender:
Credentials:AGNP
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 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-7785
Practice Address - Street 1:4500 MEMORIAL DR
Practice Address - Street 2:DEPT ANESTHESIOLOGY
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5360
Practice Address - Country:US
Practice Address - Phone:800-862-9980
Practice Address - Fax:314-362-7785
Is Sole Proprietor?:No
Enumeration Date:2013-11-11
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011680363LA2200X
MO2013044500363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420022730Medicaid