Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Jacob C Shively

Individual provider Nurse Practitioner · NPI 1215672928

Jacob C Shively is a Nurse Practitioner in Fort Wayne, Indiana. Qualified in 2021, 5 years ago. Practices with Nephrology Associates of Northern Indiana PC, a 64-clinician group, works from 2 locations and accepts Medicare assignment. Licensed in Indiana.

Years since qualifying
5
Licensed in
IN
In the registry since
2022
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Practice location Address checks out

11104 Parkview Circle Dr Ste 330
Fort Wayne, IN 46845-1674
Phone: (260) 494-3484
Fax: (260) 969-0188
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Additional practice locations (1)

  • 11104 Parkview Circle Dr Ste 110, Fort Wayne, IN 46845-1673 — (260) 425-6780

Specialties & licences

Nurse Practitioner (primary) Taxonomy 363L00000X · Licence 71012742A (IN)

Record details

NPI number1215672928
Entity typeIndividual (Type 1)
GenderMale
Sole proprietorNo
NPI enumeratedApril 28, 2022
Last updated in NPPESNovember 1, 2023
Certification dateNovember 1, 2023
Mailing address120 W 22nd St Ste 200, Oak Brook, IL 60523-1563

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyNURSE PRACTITIONER
Medical schoolOTHER
Graduated 2021 (5 years in practice)
Group practice Nephrology Associates Of Northern Indiana Pc — 64 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount

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