Provider Demographics
NPI:1801331467
Name:MCDOUGALL, JACOB WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:WILLIAM
Last Name:MCDOUGALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 E GANNON AVE
Mailing Address - Street 2:SUITE #104
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597-9309
Mailing Address - Country:US
Mailing Address - Phone:919-375-1975
Mailing Address - Fax:919-269-0240
Practice Address - Street 1:162 LEGACY OAKS DR
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6556
Practice Address - Country:US
Practice Address - Phone:919-373-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06933363A00000X
UT12689705-8906363AS0400X
UT12689705-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical