Basic Information
| Provider Information | |||||||||
| NPI: | 1801312616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | DENISA | ||||||||
| MiddleName: | DESPINA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RT (R)(CT), PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621310 | ||||||||
| FaxNumber: | 9375228068 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 W GRAND AVE STE 2002 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454054722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374254144 | ||||||||
| FaxNumber: | 9374254146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 07/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C3401X | R8861923 | OH | N | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Computed Tomography | 2471C3402X | R8861923 | OH | N | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1132364 | 01 | NCCPA | OTHER |