Provider Demographics
NPI:1235879099
Name:PACKER, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PACKER
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 1:426 STATE ST FL 1
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5739
Mailing Address - Country:US
Mailing Address - Phone:480-257-8543
Mailing Address - Fax:
Practice Address - Street 1:1107 E 66TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-5701
Practice Address - Country:US
Practice Address - Phone:912-350-8404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program