Provider Demographics
NPI:1700828795
Name:JACOB, STEPHEN CHACKO (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CHACKO
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 ROSWELL RD STE 40
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8830
Mailing Address - Country:US
Mailing Address - Phone:678-224-5334
Mailing Address - Fax:
Practice Address - Street 1:3535 ROSWELL RD STE 40
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8830
Practice Address - Country:US
Practice Address - Phone:678-224-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0411422083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine