Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | 565 | SC |
N | 222Z00000X | Podiatrist | 565 | SC |
Y | 213E00000X | Podiatrist | 847 | TN |
Y | 222Z00000X | Podiatrist | 847 | TN |
N | 213EP1101X | Primary Podiatric Medicine | 565 | SC |
N | 213EP1101X | Primary Podiatric Medicine | 847 | TN |
N | 213ES0131X | Foot Surgery | 565 | SC |
N | 213ES0131X | Foot Surgery | 847 | TN |
NPI | 1295726172 |
---|---|
Provider Name | Dr. Dwayne Aubrey Jacobus |
First Address | Cookeville, TN 38501-6037 |
Second Address | Cookeville, TN 38501-6037 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2005 |
Last Update Date | 19/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
FJ4698431 | TN DEA (01) | TN |
PD5658 | (05) | SC |
Q058390 | (05) | TN |
T14910A | MEDICARE TN (01) | TN |
U90949 | (02) | SC |