Provider Demographics
NPI:1699401877
Name:STREET, JACOB (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:STREET
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 N ROAN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2521
Mailing Address - Country:US
Mailing Address - Phone:423-283-4942
Mailing Address - Fax:
Practice Address - Street 1:2240 N ROAN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2521
Practice Address - Country:US
Practice Address - Phone:423-283-4942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist