Provider Demographics
NPI:1982574653
Name:UPCHURCH, CLABURN JACOB
Entity type:Individual
Prefix:MR
First Name:CLABURN
Middle Name:JACOB
Last Name:UPCHURCH
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 1:234 OLD JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-6946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 TREE LN
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6782
Practice Address - Country:US
Practice Address - Phone:678-205-4299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-07
Last Update Date:2025-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant