Provider Demographics
NPI:1952972036
Name:MCCANN, JACOB THOMAS
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:MCCANN
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 1:4701 MCCANN LN
Mailing Address - Street 2:
Mailing Address - City:MC LEANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27301-9776
Mailing Address - Country:US
Mailing Address - Phone:336-908-4968
Mailing Address - Fax:
Practice Address - Street 1:4701 MCCANN LN
Practice Address - Street 2:
Practice Address - City:MC LEANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27301-9776
Practice Address - Country:US
Practice Address - Phone:336-908-4968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC288033163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse