Healthcare Provider Details

I. General information

NPI: 1063209864
Provider Name (Legal Business Name): JACOB WORDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BO WORDEN

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 ORTHO LANE SOM SUITE/5TH FLOOR
ATLANTA GA
30329
US

IV. Provider business mailing address

21 ORTHO LN
ATLANTA GA
30329-2315
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-2516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: