Jacob Gray Lackey, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

0010-05288 Issued in NC

Practice address

3163 Gammon LN
Clemmons, NC 27012-9052

Phone

(336) 310-5571

Fax

(336) 310-5574

NPI assigned

Oct 3, 2014

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2014

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Appalachian Regional Medical Associates IncGroup PAC ID 5799877817, 147 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Watauga Medical Center Hospital, Boone, NC, CCN 340051
• Charles a Cannon Jr Memorial Hospital Hospital, Linville, NC, CCN 341323
• Ashe Memorial Hospital Hospital, Jefferson, NC, CCN 341325

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Interoperability endpoints

• Direct secure messaging: jlackey215351@direct.unc.nchie.net
• Direct secure messaging: jacoblackey@arhs.allscriptsdirect.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Appalachian Regional Medical Associates, Inc.

  • Family Medicine Physician
  • Boone, NC
  • NPI 1669533923
  Medicare reassignment Care Compare group

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Ashe Memorial Hospital Inc

  • Critical Access Hospital
  • Jefferson, NC
  • NPI 1376671370
  Care Compare affiliation
• Charles a Cannon Jr Memorial Hospital Inc

  • Psychiatric Hospital Unit
  • Linville, NC
  • NPI 1407006968
  Care Compare affiliation
• Charles a Cannon Jr Memorial Hospital Inc.

  • Critical Access Hospital
  • Linville, NC
  • NPI 1225088255
  Care Compare affiliation
• Watauga Medical Center Inc

  • General Acute Care Hospital
  • Boone, NC
  • NPI 1205859766
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1412294400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1629244800000",
    "number": "1699178731",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 601843",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282601843"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3163 GAMMON LN",
            "city": "CLEMMONS",
            "state": "NC",
            "postal_code": "270129052",
            "telephone_number": "336-310-5571",
            "fax_number": "336-310-5574"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LACKEY",
        "first_name": "JACOB",
        "middle_name": "GRAY",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-10-03",
        "last_updated": "2021-08-18",
        "certification_date": "2021-08-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-05288",
            "primary": true
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NC",
            "license": "001005288",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jlackey843955@direct.novanthealth.org",
            "affiliation": "N",
            "address_1": "3163 Gammon Ln",
            "city": "Clemmons",
            "state": "NC",
            "country_code": "US",
            "postal_code": "270129052",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Timothy Kmen
• Lynora Lee Knott
• Stuart Allan Kossover, MD
• Kostelic & Associates, PLLC
• Matthew Kostelic, DMD
• Stacey M Ladd, RN
• Rachel Elizabeth Lafleur, RPH
• Chelsea Lam, PHARMD
• Heysel Lam
• Savannah Lancaster, DDS

• Physician Assistant in Clemmons, NC
• Providers in Clemmons, NC by specialty
• Physician Assistant in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.