Provider Demographics
NPI:1396411617
Name:JACOBS, JAMESON
Entity Type:Individual
Prefix:DR
First Name:JAMESON
Middle Name:
Last Name:JACOBS
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 1:70 TOWNSHIP ROAD 14
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:OH
Mailing Address - Zip Code:45889-9621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 N COUNTYLINE ST
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-1766
Practice Address - Country:US
Practice Address - Phone:419-435-7716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03441057183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist