Provider Demographics
NPI:1760514285
Name:JACOBS, JOHN BARRY (DPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BARRY
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S CREST RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-5521
Mailing Address - Country:US
Mailing Address - Phone:423-622-1600
Mailing Address - Fax:
Practice Address - Street 1:145 INDUSTRIAL WAY SW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-7114
Practice Address - Country:US
Practice Address - Phone:800-614-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6383183500000X
TN20793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist