Basic Information
| Provider Information | |||||||||
| NPI: | 1225665417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RICKOLL | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1631 ELYSIAN FIELDS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701178208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048212601 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1631 ELYSIAN FIELDS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701178208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048212601 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2020 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 214020 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | 214020 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.