Provider Demographics
NPI:1780433110
Name:DARDY, JACOBIE J
Entity type:Individual
Prefix:
First Name:JACOBIE
Middle Name:J
Last Name:DARDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACOBIE
Other - Middle Name:J
Other - Last Name:DARDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JACOBIE DARDY
Mailing Address - Street 1:607 FRANK HALL JR ST # 52
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:31833-5234
Mailing Address - Country:US
Mailing Address - Phone:706-518-8901
Mailing Address - Fax:
Practice Address - Street 1:8 LAGRANGE ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2604
Practice Address - Country:US
Practice Address - Phone:706-518-8901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA24090770172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker