Provider Demographics
NPI:1568700672
Name:JACOB, DARREN R
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:R
Last Name:JACOB
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 1:917 DECATUR PIKE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3037
Mailing Address - Country:US
Mailing Address - Phone:423-744-1085
Mailing Address - Fax:423-744-1084
Practice Address - Street 1:917 DECATUR PIKE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3037
Practice Address - Country:US
Practice Address - Phone:423-744-1085
Practice Address - Fax:423-744-1084
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8045183500000X
GARPH026287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist