Provider Demographics
NPI:1972736551
Name:BRISCOE, JACOB J (CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:BRISCOE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 HAMER RD
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-6908
Mailing Address - Country:US
Mailing Address - Phone:309-210-6650
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK GROVE RD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1573
Practice Address - Country:US
Practice Address - Phone:573-776-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041341872367500000X
IL209007627367500000X
MO2024007928367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered