Provider Demographics
NPI:1992463970
Name:SHIRLEY, JACOB DANIEL (PA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:SHIRLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1925 MOUNTAIN VIEW AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3128
Mailing Address - Country:US
Mailing Address - Phone:720-718-8240
Mailing Address - Fax:720-718-0953
Practice Address - Street 1:1925 MOUNTAIN VIEW AVE FL 3
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3128
Practice Address - Country:US
Practice Address - Phone:720-718-8240
Practice Address - Fax:720-718-0953
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2025-07-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WYPA1128363A00000X
IDPA-2185363A00000X
CO0009178363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant