Provider Demographics
NPI:1699362574
Name:PHOMAS, JACOB BRADLEY
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:BRADLEY
Last Name:PHOMAS
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 1:1815 N EXPRESSWAY STE B
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-1185
Mailing Address - Country:US
Mailing Address - Phone:678-408-4622
Mailing Address - Fax:
Practice Address - Street 1:1815 N EXPRESSWAY STE B
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1185
Practice Address - Country:US
Practice Address - Phone:678-408-4622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor