Provider Demographics
NPI:1356375315
Name:JACOB, MARYANN KURUVILLA (MD)
Entity type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:KURUVILLA
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1401 ARNOLD AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4621
Mailing Address - Country:US
Mailing Address - Phone:678-662-0288
Mailing Address - Fax:
Practice Address - Street 1:1001 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1605
Practice Address - Country:US
Practice Address - Phone:404-785-4982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0585622084P0804X
MI43010864522084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry