Provider Demographics
NPI:1619394855
Name:GINGERICH, JACOB (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GINGERICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ADMINISTRATION RD
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-8822
Mailing Address - Country:US
Mailing Address - Phone:865-483-7030
Mailing Address - Fax:865-483-3954
Practice Address - Street 1:120 ADMINISTRATION RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-8822
Practice Address - Country:US
Practice Address - Phone:865-483-7030
Practice Address - Fax:865-483-3954
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3696208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ049564Medicaid