Healthcare Provider Details

I. General information

NPI: 1114647120
Provider Name (Legal Business Name): JACOB STERRY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 FALCON CREST LN
CLYDE NC
28721-6620
US

IV. Provider business mailing address

PO BOX 1921
CLYDE NC
28721-1921
US

V. Phone/Fax

Practice location:
  • Phone: 828-818-8808
  • Fax:
Mailing address:
  • Phone: 828-818-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: