Provider Demographics
NPI:1922891894
Name:FARRELL, JACOB RICHARD (DNAP, CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RICHARD
Last Name:FARRELL
Suffix:
Gender:M
Credentials:DNAP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25111 N 21ST AVE UNIT 142
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0060
Mailing Address - Country:US
Mailing Address - Phone:630-240-3186
Mailing Address - Fax:
Practice Address - Street 1:10401 W THUNDERBIRD BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3004
Practice Address - Country:US
Practice Address - Phone:630-240-3186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-23
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251095367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered