Provider Demographics
NPI:1174925309
Name:WEIRICH, JACOB A (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:WEIRICH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:WEIRICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2635 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8209
Mailing Address - Country:US
Mailing Address - Phone:970-298-2551
Mailing Address - Fax:970-298-2818
Practice Address - Street 1:2635 N 7TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501
Practice Address - Country:US
Practice Address - Phone:970-298-2551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5823363A00000X
COPA.0004273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO553172YYS0OtherMEDICARE B FOR MOUNTAIN PEAKS URGENT CARE
CO22506080Medicaid
CO553172YYS0OtherMEDICARE B FOR MOUNTAIN PEAKS URGENT CARE