Healthcare Provider Details

I. General information

NPI: 1629648209
Provider Name (Legal Business Name): JACOB ALBERT WOOTEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 MALLARD LN
LYNCHBURG VA
24502-1154
US

IV. Provider business mailing address

162 MALLARD LN
LYNCHBURG VA
24502-1154
US

V. Phone/Fax

Practice location:
  • Phone: 434-420-1816
  • Fax:
Mailing address:
  • Phone: 434-420-1816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008161
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: