Basic Information
| Provider Information | |||||||||
| NPI: | 1285698670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | LEE DINE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 NEWMARK DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453425400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374388910 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2615 E HIGH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455051412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373250531 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 07/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34.005854 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0986116 | 05 | OH | MEDICAID | 000000017441 | 01 | OH | ANTHEM | OTHER |