Provider Demographics
NPI:1396939971
Name:COWARD, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:COWARD
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 1:518 E CAROLINA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4312
Mailing Address - Country:US
Mailing Address - Phone:843-383-4426
Mailing Address - Fax:843-383-8509
Practice Address - Street 1:518 E CAROLINA AVE STE B
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4312
Practice Address - Country:US
Practice Address - Phone:843-383-4426
Practice Address - Fax:843-383-8509
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3317363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20066947OtherSELECT HEALTH
SC3317OtherSC LICENSE #
SCNP1148Medicaid
SC3317OtherSC LICENSE #