Provider Demographics
NPI:1104916667
Name:JACOBS, AMY JOHNSON (PHARM D)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:JOHNSON
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2698 SCARBORO HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY FORD
Mailing Address - State:GA
Mailing Address - Zip Code:30455-6814
Mailing Address - Country:US
Mailing Address - Phone:912-863-6173
Mailing Address - Fax:
Practice Address - Street 1:730 S LEWIS ST
Practice Address - Street 2:
Practice Address - City:METTER
Practice Address - State:GA
Practice Address - Zip Code:30439-5127
Practice Address - Country:US
Practice Address - Phone:912-685-5170
Practice Address - Fax:912-685-2388
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist