Healthcare Provider Details

I. General information

NPI: 1972736551
Provider Name (Legal Business Name): JACOB J BRISCOE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 OAK GROVE RD
POPLAR BLUFF MO
63901-1573
US

IV. Provider business mailing address

1201 HAMER RD
DYERSBURG TN
38024-6908
US

V. Phone/Fax

Practice location:
  • Phone: 573-776-2000
  • Fax:
Mailing address:
  • Phone: 309-210-6650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041341872
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209007627
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2024007928
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: