Provider Demographics
NPI:1295391944
Name:WHITE, JACOB III
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WHITE
Suffix:III
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 1:570 RUSSELL RD APT 5
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-1900
Mailing Address - Country:US
Mailing Address - Phone:419-961-5745
Mailing Address - Fax:
Practice Address - Street 1:16 W LONG ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2815
Practice Address - Country:US
Practice Address - Phone:614-225-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist