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General NPI Number Information
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NPI Number | 1568118172
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Entity Type | Individual
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Provider Name | JACOB WALLIS
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Gender | Male
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Dates
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Enumeration Date | 02/23/2022
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Last Update Date | 11/21/2024
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Provider Practice Location Address
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Address Line | 104 N PARK DR
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-1645
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Country | US
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Telephone | 470-944-5290
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Fax |
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Provider Business Mailing Address
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Address Line | 206 OXFORD RD
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City | NEW ALBANY
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State | MS
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Zip | 38652-3115
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Country | US
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Telephone | 662-534-2227
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Fax | 662-534-2330
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 4879
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License Number State | TN
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