Provider Demographics
NPI:1164264719
Name:JACOBS, TISHA CHAVIS
Entity type:Individual
Prefix:
First Name:TISHA
Middle Name:CHAVIS
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 KATIE BUIE RD
Mailing Address - Street 2:
Mailing Address - City:RED SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28377-4600
Mailing Address - Country:US
Mailing Address - Phone:706-304-8870
Mailing Address - Fax:
Practice Address - Street 1:236 KATIE BUIE RD
Practice Address - Street 2:
Practice Address - City:RED SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28377-4600
Practice Address - Country:US
Practice Address - Phone:706-304-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health