Provider Demographics
NPI:1033687207
Name:JACOBS, ASHLEY LEE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LEE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3674 BRACKNELL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9160
Mailing Address - Country:US
Mailing Address - Phone:614-749-2121
Mailing Address - Fax:
Practice Address - Street 1:3674 BRACKNELL FOREST DR
Practice Address - Street 2:
Practice Address - City:GROVEPORT
Practice Address - State:OH
Practice Address - Zip Code:43125-9160
Practice Address - Country:US
Practice Address - Phone:614-749-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082025Medicaid