Provider Demographics
NPI:1497232565
Name:FOUNTAIN, JACOB J (FNP)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:J
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W FARIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-3002
Mailing Address - Country:US
Mailing Address - Phone:917-696-6622
Mailing Address - Fax:
Practice Address - Street 1:225 ENTERPRISE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-454-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21977363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily