Provider Demographics
NPI:1730367483
Name:JAMES WYNN JACOBS,M.D.
Entity type:Organization
Organization Name:JAMES WYNN JACOBS,M.D.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WYNN
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-582-1211
Mailing Address - Street 1:1436 GUNTER AVE
Mailing Address - Street 2:P.O.BOX 938
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-1846
Mailing Address - Country:US
Mailing Address - Phone:256-582-1211
Mailing Address - Fax:256-582-2522
Practice Address - Street 1:1436 GUNTER AVE
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-1846
Practice Address - Country:US
Practice Address - Phone:256-582-1211
Practice Address - Fax:256-582-2522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J.WYNN JACOBS,M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-05
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13234332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000017960Medicaid
ALC47412Medicare UPIN
AL000017960Medicaid