Provider Demographics
NPI:1568657062
Name:SMITH, JACOB BRYAN (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:BRYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 CIRCLE ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:PA
Mailing Address - Zip Code:16323-2509
Mailing Address - Country:US
Mailing Address - Phone:814-437-2191
Mailing Address - Fax:814-437-2264
Practice Address - Street 1:44 CIRCLE ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323-2509
Practice Address - Country:US
Practice Address - Phone:814-437-2191
Practice Address - Fax:814-437-2264
Is Sole Proprietor?:No
Enumeration Date:2007-09-08
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2806207X00000X
OH34.009352207X00000X
OH34009352207XS0117X
FLOS11241207XS0117X
PAOS019134207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPENDINGMedicaid
OH0092168Medicaid
OH0092168Medicaid
OHFS4302915Medicare PIN