Provider Demographics
NPI:1942686316
Name:JACOB, DARYL (CAA)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1968 PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 MICHIGAN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2916
Practice Address - Country:US
Practice Address - Phone:888-884-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7680367H00000X
367H00000X
DCAA000080207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCAA000080OtherNCCAA CERTIFICATION