Provider Demographics
NPI:1043965684
Name:BARBARA, JAKE ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:ANTHONY
Last Name:BARBARA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WHITE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28545
Mailing Address - Country:US
Mailing Address - Phone:910-449-6500
Mailing Address - Fax:
Practice Address - Street 1:100 WHITE STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28545
Practice Address - Country:US
Practice Address - Phone:910-449-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102208195208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program