Basic Information
| Provider Information | |||||||||
| NPI: | 1215227202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAULK | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 TILLMAN PAULK RD | ||||||||
| Address2: | |||||||||
| City: | AMBROSE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315123486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295485137 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 18TH ST E | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293536124 | ||||||||
| FaxNumber: | 2293537722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2011 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN181759 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | RN181759 | 01 | GA | STATE LICENSE | OTHER |