Provider Demographics
NPI:1255982039
Name:MATHEW, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MATHEW
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 1:295 LUMPKIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-5561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 JESSE JEWELL PKWY SE STE 300
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3865
Practice Address - Country:US
Practice Address - Phone:770-532-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant