Basic Information
| Provider Information | |||||||||
| NPI: | 1447447503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5170 US RT 60 EAST | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045284600 | ||||||||
| FaxNumber: | 3047333143 | ||||||||
| Practice Location | |||||||||
| Address1: | 5170 US ROUTE 60 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257052004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045284600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1310 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1447447503 | 05 | WV | MEDICAID | 0356376 | 05 | OH | MEDICAID | 7100109200 | 05 | KY | MEDICAID |