Provider Demographics
NPI:1073070884
Name:MASTERS, JACOB DALE
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DALE
Last Name:MASTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 FLOWERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:WEST CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-3217
Mailing Address - Country:US
Mailing Address - Phone:937-422-8598
Mailing Address - Fax:
Practice Address - Street 1:2706 FLOWERSTONE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-3217
Practice Address - Country:US
Practice Address - Phone:937-422-8598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0317945Medicaid