Provider Demographics
NPI:1922074459
Name:FERDINAND-JACOB, GWENETH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:GWENETH
Middle Name:
Last Name:FERDINAND-JACOB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 MCCLAIN DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5695
Mailing Address - Country:US
Mailing Address - Phone:931-906-1823
Mailing Address - Fax:731-352-7644
Practice Address - Street 1:763 MCCLAIN DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040
Practice Address - Country:US
Practice Address - Phone:931-906-1823
Practice Address - Fax:731-352-7644
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA969363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYVAD000Medicare UPIN