Healthcare Provider Details

I. General information

NPI: 1215227202
Provider Name (Legal Business Name): JACOB PAULK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 18TH ST E
TIFTON GA
31794-3648
US

IV. Provider business mailing address

209 TILLMAN PAULK RD
AMBROSE GA
31512-3486
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-6124
  • Fax: 229-353-7722
Mailing address:
  • Phone: 229-548-5137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN181759
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: