Basic Information
| Provider Information | |||||||||
| NPI: | 1063611853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | LIESL | ||||||||
| MiddleName: | JADE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377522310 | ||||||||
| FaxNumber: | 9375228493 | ||||||||
| Practice Location | |||||||||
| Address1: | 5350 LAMME RD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454393215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375344651 | ||||||||
| FaxNumber: | 9375344669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35.097603 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0067987 | 05 | OH | MEDICAID | QMP000004762758 | 01 | OH | MOLINA | OTHER | 000000915098 | 01 | OH | ANTHEM | OTHER |