Provider Demographics
NPI:1174157572
Name:MAXWELL, JACOB PAUL (RN, DNP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PAUL
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:RN, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 W STATE ST APT A203
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8131
Mailing Address - Country:US
Mailing Address - Phone:661-858-7555
Mailing Address - Fax:
Practice Address - Street 1:11262 CAMPUS ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1727
Practice Address - Country:US
Practice Address - Phone:909-558-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA95015683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program