Provider Demographics
NPI:1417284498
Name:CANTRELL, JACOB BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:BRUCE
Last Name:CANTRELL
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 1:975 E. THIRD STREET
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37043
Mailing Address - Country:US
Mailing Address - Phone:423-266-1490
Mailing Address - Fax:423-778-2108
Practice Address - Street 1:975 E. THIRD STREET
Practice Address - Street 2:ATTN: PROVIDER ENROLLMENT
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-266-1490
Practice Address - Fax:423-778-2108
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN54013207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist