Provider Demographics
NPI:1902575509
Name:JULIAN, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JULIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 DECATUR ST SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3204
Mailing Address - Country:US
Mailing Address - Phone:716-984-8068
Mailing Address - Fax:
Practice Address - Street 1:140 DECATUR ST SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3204
Practice Address - Country:US
Practice Address - Phone:716-984-8068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program