Provider Demographics
NPI:1326510751
Name:PARKER, JACOB C (DO, MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:C
Last Name:PARKER
Suffix:
Gender:M
Credentials:DO, MD
Other - Prefix:DR
Other - First Name:CHRISTEN
Other - Middle Name:
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:300 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7715
Mailing Address - Country:US
Mailing Address - Phone:601-329-1321
Mailing Address - Fax:
Practice Address - Street 1:300 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7715
Practice Address - Country:US
Practice Address - Phone:601-307-5339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-24
Last Update Date:2024-04-26
Deactivation Date:2020-09-22
Deactivation Code:
Reactivation Date:2021-07-20
Provider Licenses
StateLicense IDTaxonomies
IL8420042213103TP0814X
MSMS80885163WC0400X
HI800341120246Z00000X
MS800341120246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Single Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251123217211OtherCLIA LICENSES
MS7NQ3-KD9-CK19Medicaid
MS800341120Medicaid
MS25187411OtherCLINICAL LABORATORY IMPROVEMENT AMENDMENTS
MSMS80885OtherMEDICAL LICENSES
MS314125401870Medicaid