Provider Demographics
NPI:1609250141
Name:FARRIS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:FARRIS
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 1:111 N MARIETTA PKWY NE
Mailing Address - Street 2:APT B120
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1478
Mailing Address - Country:US
Mailing Address - Phone:678-549-3947
Mailing Address - Fax:
Practice Address - Street 1:1984 PEACHTREE RD NW
Practice Address - Street 2:SUITE 515
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-5219
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant