Provider Demographics
NPI:1184503245
Name:NEWELL, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:NEWELL
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 1:2945 MOUNTAIN VW APT 202
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-2606
Mailing Address - Country:US
Mailing Address - Phone:267-393-6671
Mailing Address - Fax:
Practice Address - Street 1:2945 MOUNTAIN VW APT 202
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-2606
Practice Address - Country:US
Practice Address - Phone:267-393-6671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-01
Last Update Date:2025-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704384619NSA250PU363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health