Basic Information
| Provider Information | |||||||||
| NPI: | 1407856214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | NORMAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403566942 | ||||||||
| FaxNumber: | 7403567851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 27TH ST | ||||||||
| Address2: | SOMC | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568117 | ||||||||
| FaxNumber: | 7403531214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 35050302 | OH | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 51107 | KY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 35050302 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0635389 | 05 | OH | MEDICAID | P00176289 | 01 | OH | SOM RR MDCR PIN NUMBER | OTHER | TP318 | 01 | KY | KENTUCKY MEDICAL LICENSE | OTHER | 6478787200 | 05 | KY | MEDICAID | 000000203530 | 01 | OH | BC/BS INDIVIDUAL PIN NO | OTHER |