Healthcare Provider Details

I. General information

NPI: 1063330363
Provider Name (Legal Business Name): JACOB EDWARD SPOON FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N CHURCH ST STE 939
THOMASTON GA
30286-3622
US

IV. Provider business mailing address

855 N CHURCH ST STE 939
THOMASTON GA
30286-3622
US

V. Phone/Fax

Practice location:
  • Phone: 762-417-1055
  • Fax: 762-417-1056
Mailing address:
  • Phone: 762-417-1055
  • Fax: 762-417-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP311338
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: