Provider Demographics
NPI:1407685373
Name:MATHIEU, JACOB BRIAN (APRN)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BRIAN
Last Name:MATHIEU
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8047 DENNIS FOX LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37938-3363
Mailing Address - Country:US
Mailing Address - Phone:985-855-2976
Mailing Address - Fax:
Practice Address - Street 1:1787 VETERANS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-6946
Practice Address - Country:US
Practice Address - Phone:865-428-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36790363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner