Provider Demographics
NPI:1831462787
Name:DUKE, JACOB L
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:L
Last Name:DUKE
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 1:274 RIVERVIEW DR N
Mailing Address - Street 2:
Mailing Address - City:DECATURVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38329-5353
Mailing Address - Country:US
Mailing Address - Phone:731-852-2036
Mailing Address - Fax:
Practice Address - Street 1:179 TENNESSEE AVE N
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-2002
Practice Address - Country:US
Practice Address - Phone:731-847-3784
Practice Address - Fax:731-847-6167
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist