Provider Demographics
NPI:1114649936
Name:LANDRAM, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LANDRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4396 BRIARCLIFF RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2155
Mailing Address - Country:US
Mailing Address - Phone:256-783-1871
Mailing Address - Fax:
Practice Address - Street 1:4396 BRIARCLIFF RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2155
Practice Address - Country:US
Practice Address - Phone:256-783-1871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant