Provider Demographics
NPI:1063663284
Name:PERRY, JACOB E (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:E
Last Name:PERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1077
Mailing Address - Country:US
Mailing Address - Phone:606-784-7551
Mailing Address - Fax:606-784-1184
Practice Address - Street 1:425 CLINIC DR
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1077
Practice Address - Country:US
Practice Address - Phone:606-784-7551
Practice Address - Fax:606-784-1184
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44487208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100164220Medicaid
KY44487OtherSTATE LICENSE
KYK003150Medicare PIN