Provider Demographics
NPI:1770281784
Name:EVANSUN, JACOB (FNP-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:EVANSUN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 WOODGROVE DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-7509
Mailing Address - Country:US
Mailing Address - Phone:253-314-2374
Mailing Address - Fax:
Practice Address - Street 1:774 ATHENS RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:GA
Practice Address - Zip Code:30648-1908
Practice Address - Country:US
Practice Address - Phone:706-743-8183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN278189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily