Healthcare Provider Details

I. General information

NPI: 1730323254
Provider Name (Legal Business Name): JACOB EDWARDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 WINN WAY
DECATUR GA
30030-2106
US

IV. Provider business mailing address

1528 MONARCH DR
MARIETTA GA
30062-2748
US

V. Phone/Fax

Practice location:
  • Phone: 404-508-1177
  • Fax: 404-508-9640
Mailing address:
  • Phone: 404-213-1581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.31940
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: