Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Jacob Wallis

Individual provider Physician Assistant · NPI 1568118172

Jacob Wallis is a Physician Assistant in Fayetteville, Georgia. Qualified in 2021, 5 years ago. Works from 3 locations and accepts Medicare assignment. Licensed in Tennessee.

Years since qualifying
5
Licensed in
TN
In the registry since
2022
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Practice location Address checks out

104 N Park Dr
Fayetteville, GA 30214-1645
Phone: (470) 944-5290
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Additional practice locations (2)

  • 60 John C Breckenridge Cv, Adamsville, TN 38310-5089 — (731) 646-0182
  • 6515 Poplar Ave Ste 106, Memphis, TN 38119-4878 — (901) 426-1090

Specialties & licences

Physician Assistant (primary) Taxonomy 363A00000X · Licence 4879 (TN)

Record details

NPI number1568118172
Entity typeIndividual (Type 1)
GenderMale
Sole proprietorNo
NPI enumeratedFebruary 23, 2022
Last updated in NPPESNovember 21, 2024
Certification dateNovember 21, 2024
Mailing address206 Oxford Rd, New Albany, MS 38652-3115

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICIAN ASSISTANT
Medical schoolOTHER
Graduated 2021 (5 years in practice)
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations2 on file with Medicare

Other providers in Fayetteville