Provider Demographics
NPI:1861119687
Name:SKILLERN, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SKILLERN
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 1:3433 W SHAW AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3229
Mailing Address - Country:US
Mailing Address - Phone:595-558-4051
Mailing Address - Fax:
Practice Address - Street 1:301 E 13TH ST STE D
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6211
Practice Address - Country:US
Practice Address - Phone:209-386-1096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2025-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40357167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician