Provider Demographics
NPI:1306043096
Name:ENTERKIN, JACOB ELIDGE
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ELIDGE
Last Name:ENTERKIN
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:PO BOX 1339
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-1339
Mailing Address - Country:US
Mailing Address - Phone:318-388-2646
Mailing Address - Fax:318-388-2843
Practice Address - Street 1:1304 W BOBO NEWSOM HWY
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4710
Practice Address - Country:US
Practice Address - Phone:843-339-4790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL29855207Q00000X
SC298552085R0202X
LA3054162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine