Individual
JACOB GRAY LACKEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3163 GAMMON LN, CLEMMONS, NC 27012-9052
(336) 310-5571
(336) 310-5574
Mailing address
PO BOX 601843, CHARLOTTE, NC 28260-1843
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0010-05288
NC
363AM0700X
Medical Physician Assistant
001005288
NC
Other
Enumeration date
10/03/2014
Last updated
08/18/2021
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