Provider Demographics
NPI:1184213076
Name:CHESNUTT, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CHESNUTT
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 1:785 CHICKAMAUGA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-1477
Mailing Address - Country:US
Mailing Address - Phone:706-866-1220
Mailing Address - Fax:
Practice Address - Street 1:785 CHICKAMAUGA AVE
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-1477
Practice Address - Country:US
Practice Address - Phone:706-866-1220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23119183500000X
390200000X
GARPH034675183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program