Provider Demographics
NPI:1679391965
Name:WANGERIEN, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WANGERIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6890 BARRED DOVE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2656
Mailing Address - Country:US
Mailing Address - Phone:702-332-7641
Mailing Address - Fax:
Practice Address - Street 1:6890 BARRED DOVE LN
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-2656
Practice Address - Country:US
Practice Address - Phone:702-332-7641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant