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

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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