Provider Demographics
NPI:1336224260
Name:WARD, JACOB (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 VILLAGE PROFESSIONAL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8499
Mailing Address - Country:US
Mailing Address - Phone:678-661-4545
Mailing Address - Fax:
Practice Address - Street 1:2000 VILLAGE PROFESSIONAL DR STE 200
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8499
Practice Address - Country:US
Practice Address - Phone:678-661-4545
Practice Address - Fax:678-880-8151
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA32075207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE81366Medicare UPIN
GA08BBQHDMedicare ID - Type Unspecified