Basic Information
| Provider Information | |||||||||
| NPI: | 1518961531 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 MIAMI VALLEY DR | ||||||||
| Address2: | STE 550 | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454591298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374387500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11091 ULYSSES STREET | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128791000 | ||||||||
| FaxNumber: | 6128790782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 37807 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 160230600 | 05 | MN | MEDICAID |