Provider Demographics
NPI:1376599712
Name:JACOBS, KATHERINE ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ANNE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:K.
Other - Middle Name:ANNE
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5883 HICKORY TRL
Mailing Address - Street 2:
Mailing Address - City:N RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-2650
Mailing Address - Country:US
Mailing Address - Phone:216-272-2663
Mailing Address - Fax:
Practice Address - Street 1:37500 HARVEST AVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-2804
Practice Address - Country:US
Practice Address - Phone:216-272-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20150207W00000X
PAMD447449207W00000X
FLME60862207W00000X
LAMD017041207W00000X
OH35052754207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHE52754OtherSUMMA HEALTH CARE
OH140766OtherANTHEM PIN #
OH0632088Medicaid
PA1027671530001Medicaid
OH107166OtherKAISER
OH107166OtherKAISER
OH140766OtherANTHEM PIN #
OH4223391Medicare PIN
WVWV1929AMedicare PIN