Provider Demographics
NPI:1699023077
Name:JACOT, DUSTIN A (PA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:A
Last Name:JACOT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 9TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6248
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:550 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8160
Practice Address - Country:US
Practice Address - Phone:707-465-6925
Practice Address - Fax:707-465-6070
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant