1497029672 NPI number — JENNIFER E JACOBS DPM LLC

Table of content: THOMAS PATRICK BANTA (NPI 1528804523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497029672 NPI number — JENNIFER E JACOBS DPM LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENNIFER E JACOBS DPM LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497029672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1747 LANGFORD DRIVE
Provider Second Line Business Mailing Address:
BLD. 400 STE. 102
Provider Business Mailing Address City Name:
WATKINSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30677-7370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-425-5433
Provider Business Mailing Address Fax Number:
770-573-6764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1747 LANGFORD DRIVE
Provider Second Line Business Practice Location Address:
BLD. 400 STE. 102
Provider Business Practice Location Address City Name:
WATKINSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30677-7370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-425-5433
Provider Business Practice Location Address Fax Number:
770-573-6764
Provider Enumeration Date:
03/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
706-425-5433

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  POD001149 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003125064A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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