Healthcare Provider Details

I. General information

NPI: 1043965684
Provider Name (Legal Business Name): JAKE ANTHONY BARBARA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2022
Last Update Date: 11/08/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHITE STREET
JACKSONVILLE NC
28545
US

IV. Provider business mailing address

100 WHITE STREET
JACKSONVILLE NC
28545
US

V. Phone/Fax

Practice location:
  • Phone: 910-449-6500
  • Fax:
Mailing address:
  • Phone: 910-449-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102208195
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: