Healthcare Provider Details

I. General information

NPI: 1609511740
Provider Name (Legal Business Name): JACOB ROY PARKER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1063 NATHAN DEAN BYP
ROCKMART GA
30153-2011
US

IV. Provider business mailing address

PO BOX 12938 C/O CLINIC MANAGEMENT
CALHOUN GA
30703
US

V. Phone/Fax

Practice location:
  • Phone: 678-685-9517
  • Fax: 770-647-8836
Mailing address:
  • Phone: 706-602-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number105337
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL.5754R
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: