Provider Demographics
NPI:1467196782
Name:LARISON, JACOB ALEXANDER (FNP-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALEXANDER
Last Name:LARISON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 CHERRY TREE BND
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2602
Mailing Address - Country:US
Mailing Address - Phone:682-216-9595
Mailing Address - Fax:
Practice Address - Street 1:115 GENEVIEVE CT
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4803
Practice Address - Country:US
Practice Address - Phone:682-216-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN299713163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse