Provider Demographics
NPI:1689489502
Name:TUTTLE, JACOB THEODORE (CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THEODORE
Last Name:TUTTLE
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 1:1967 COBBLESTONE CIR NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-4906
Mailing Address - Country:US
Mailing Address - Phone:404-862-2253
Mailing Address - Fax:
Practice Address - Street 1:1520 CLIFTON RD NE OFC 117
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4201
Practice Address - Country:US
Practice Address - Phone:404-727-6946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN292693163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse